A MANUAL 



PERCUSSION AND AUSCULTATION; 



PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNGS 
AND HEART, AND OF THORACIC ANEURISM. 



BY 

AUSTIN FLINT, M.D., 

PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE AND OF 

CLINICAL MEDICINE IN THE BELLEVUE HOSPITAL 

MEDICAL COLLEGE, ETC. ETC. 





PHILADELPHIA: 
HENRY C. LEA 

1876. 









Entered according to the Act of Congress, in the year 1876, by 

HENRY C. LEA, 
in the Office of the Librarian of Congress. All rights reserved. 



PHILADELPHIA: 
COLLI X S , PRINTER 

70o Jayne Street. 



PREFACE 



This work contains the substance of the lessons 
which the author has for many years given, in con- 
nection with practical instruction in percussion and 
auscultation, to private classes composed of medical 
students and practitioners. 

In his courses of practical instruction, his plan 
has been, 1st. To simplify the subject as much as 
possible, avoiding all needless refinements ; 2d. To 
consider the distinctive characters of the different 
physical signs as determined, not by analogies, nor 
by deductions from physics, but by analysis, and as 
based especially on variations in the intensity, pitch, 
and quality of sounds ; 3d. To impress the fact 
that the significance of physical signs relates to 
certain physical conditions, and the importance of a 
familiar acquaintance with these conditions, as well 
as with the distinctive characters of the signs by 
which they are represented • 4th. To enforce the 
necessity of sufficient study of the physical conditions 
and the signs of health, as a sine qua non for success 
in the study of the physical diagnosis of diseases ; 



IV PREFACE. 

and, 5th. To waive discussion of the mechanism of 
signs, whenever this is open for discussion, taking 
the ground that our knowledge of the significance 
of signs rests solely on the constancy of their con- 
nection with the physical conditions which they 
represent. 

This* plan has been pursued in writing the book, 
which the author hopes may be found useful, not 
only to medical students engaged in the practical 
study of percussion and auscultation, but, as a hand- 
book for reference, to the practitioner of medicine. 

New York, June, 1876. 



CONTENTS 



CHAPTER I. 

INTRODUCTION. 

PAGE 

Definition of percussion and auscultation — The sounds obtained by 
these methods representing healthy and morbid physical condi- 
tions — Definition of signs — The basis of our knowledge of signs 
the constancy of association of certain sounds with certain phy- 
sical conditions in health and disease — The present state of per- 
fection of our knowledge of signs furnished by percussion and 
auscultation — Requirements for the successful study of these 
methods of exploration — The anatomy and physiology of the 
chest — An enumeration of the points relating thereto which are 
of especial importance — The physical conditions incident to the 
different diseases of the chest : the conditions relating to the re- 
spiratory system stated, and a summary of them — The distinctive 
characters of healthy and morbid signs; variations in intensity, 
pitch, and quality, considered as the chief source of the cha- 
racters distinguishing the signs of disease from each other and 
from those of health — Other distinctions than those of intensity, 
pitch, and quality — The analytical method of the study of per- 
cussion and auscultation — The significance of the signs as re- 
gards the physical conditions which they severally represent — 
Morbid conditions, not individual diseases, represented by the 
morbid signs — Regional divisions of the chest — Anatomical rela- 
tions of the regions severally to the parts within the chest . . 13 



CHAPTER II. 

PERCUSSION IN HEALTH. 

Percussion with the fingers or with a percussor and pleximeter — The 
normal vesicular resonance on percussion ; its distinctive cha- 
racters relating to intensity, pitch, and quality — Variations in the 
characters of the normal vesicular resonance in different persons 

1* 



VI CONTENTS 



— Relations of the pitch of resonance to the vesicular quality — 
Tympanitic resonance over the abdomen — Variations of the nor- 
mal resonance in the different regions of the chest — Enumeration 
of the regions in which the resonance on the two sides varies, 
and those in which it is identical in health — Influence of age on 
the normal resonance — Influence of the acts of respiration on the 
resonance — Rules in the practice of percussion .... 40 



CHAPTER III. 

PERCUSSION IN DISEASE. 

Enumeration of the signs of disease furnished by percussion — Re- 
quirements for a practical knowledge of these signs — The distinc- 
tive characters of, the morbid physical conditions represented by, 
and the different diseases into the diagnosis of which enter, these 
signs, severally, to wit, 1. Absence of resonance or flatness; 2. 
Diminished resonance ordulness; 3. Tympanitic resonance; 4. 
Vesiculo-tympanitic resonance; 5. Amphoric resonance; 6. 
Cracked metal resonance — Sense of resistance felt in the practice 
of percussion as a morbid sign . . . . . . .58 



CHAPTER IV. 

AUSCULTATION IN HEALTH. 

Importance of the study of the auscultatory sounds in health — 
Immediate and mediate auscultation — Advantages of the binau- 
ral stethoscope — Rules to be observed in auscultation — Divisions 
of the study of auscultation in health — The normal laryngeal and 
tracheal respiration — The normal vesicular murmur; its distinc- 
tive characters ; and the variations in the different regions on the 
same side, and in corresponding regions on the two sides of the 
chest — The normal vocal resonance — The laryngeal and tracheal 
voice and whisper — The normal thoracic vocal resonance and fre- 
mitus ; the distinctive characters of each ; the variations in differ- 
ent regions on the same side, and in corresponding regions on 
the two sides of the chest — The normal bronchial whisper, with 
its variations in different regions on the same side, and in corre- 
sponding regions on the two sides of the chest .... 



CONTENTS. Vll 

CHAPTER V. 

AUSCULTATION IIS" DISEASE. 

PAGE 

The respiratory signs of disease : — Abnormal modifications of the 
normal respiratory sounds : — Increased vesicular murmur — Dimi- 
nished vesicular murmur — Suppressed respiratory sound — Bron- 
chial or tubular respiration — Broncho-vesicular respiration — 
Cavernous respiration — Broncho-cavernous respiration — Ampho- 
ric respiration — Shortened inspiration — Prolonged expiration — 
Interrupted respiration. Adventitious respiratory sounds or 
rales : — Laryngeal and tracheal rales — Moist bronchial rales, 
coarse, fine, and subcrepitant — Vesicular or crepitant rale — 
Cavernous or gurgling rale — Pleural friction rales, metallic tink- 
ling and splashing. Indeterminate rales — The vocal signs of 
disease : — Bronchophony — Whispering bronchophony — 2Ego- 
phony — Increased vocal resonance — Increased bronchial whisper 
— Cavernous whisper — Pectoriloquy — Amphoric voice or echo — 
Diminished and suppressed vocal resonance — Diminished and 
suppressed vocal fremitis — Metallic tinkling. Signs obtained by 
acts of coughing or tussive signs . . . . . . .90 

CHAPTER VI. 

THE PHYSICAL DIAGNOSIS OF DISEASES OF THE RESPIRATORY 

SYSTEM. 

Affections of the larynx and trachea — Bronchitis seated in large bron- 
chial tubes — Bronchitis seated in small bronchial tubes, or capil- 
lary bronchitis — Collapse of pulmonary lobules — Lobular pneumo- 
nia — Asthma — Pulmonary or vesicular emphysema — Pleurisy, 
acute and chronic — Empyema — Hydrothorax — Pneumothorax — 
Pneumo-hydrothorax — Acute lobar pneumonia — Circumscribed 
pneumonia — Embolic pneumonia — Hemorrhagic infarctus — Pul- 
monary apoplexy — Pulmonary gangrene — Pulmonary oedema — 
Carcinoma of lung — Tumor within the chest — Acute miliary tuber- 
culosis — Phthisis — Eibroid phthisis — Interstitial pneumonia or 
cirrhosis of lung — Diaphragmatic hernia ..... 143 

CHAPTER VII. 

THE PHYSICAL CONDITIONS OF THE HEART IN HEALTH AND 
DISEASE. THE HEART SOUNDS AND CARDIAC MURMURS. 

Physical conditions of the heart in health : — Boundaries of the 
praecordia — Normal situation of the apex-beat — Boundaries of 



V1U CONTENTS. 



the deep and of the superficial cardiac space — Relations of the 
aorta and the pulmonary aitery to the walls of the chest — 
The heart-sounds — Characters distinguishing the first and the 
second sound — Mechanism of the production of the heart-sounds 
— Auscultation of the pulmonic and the aortic second sound 
separately — Movements of the auricles and ventricles in relation 
to each other — Physical conditions of the heart in disease : — 
Enlargement of the heart — Hypertrophy and dilatation — Ab- 
normal impulses of the heart, and modifications of the apex- 
heat — Valvular lesions — Roughness of the pericardial surfaces 
— Liquid within the pericardial sac — Abnormal modifications of 
the heart-sounds — Reduplication of heart-sounds — Cardiac mur- 
murs — Normal and abnormal blood-currents within the heart, 
and their relations with the heart-sounds — Mitral direct murmur 
— Mitral regurgitant murmur — Mitral systolic non-regurgitant, 
or intra-ventricular murmur — Aortic direct murmur — Aortic 
regurgitant murmur, and an aortic diastolic non-regurgitant 
murmur — Coexisting endocardial murmurs — Tricuspid direct 
murmur — Tricuspid regurgitant murmur — Pulmonic direct mur- 
mur — Pulmonic regurgitant murmur — Facts of practical impor- 
tance in relation to endocardial murmurs — Pericardial or friction 
murmur ........... 191 



CHAPTER VIII. 

THE PHYSICAL DIAGNOSIS OF DISEASES OP THE HEART AKD OF 
THORACIC ANEURISM. 

Enlargement of the heart by hypertrophy and dilatation — Valvular 
lesions, mitral, aortic, tricuspid, and pulmonic — Fatty degenera- 
tion and softening of the heart — Endocarditis — Pericarditis — 
Functional disorders — Thoracic aneurism ..... 229 



MANUAL 



OF 



PERCUSSION AND AUSCULTATION, 



CHAPTER I 

INTRODUCTION. 



Definition of percussion and auscultation — The sounds obtained by these 
methods representing healthy and morbid physical conditions — Defini- 
tion of signs — The basis of our knowledge of signs the constancy of 
association of certain sounds with certain physical conditions in 
health and disease — The present state of perfection of our knowledge 
of signs furnished by percussion and auscultation — Requirements for 
the successful study of these methods of exploration — The anatomy 
and physiology of the chest — An enumeration of the points relating 
thereto which are of especial importance — The physical conditions 
incident to the different diseases of the chest ; the conditions relating 
to the respiratory system stated, and a summary of them— The distinc- 
tive characters of healthy and morbid signs ; variations in intensity, 
pitch, and quality, considered as the chief source of the characters 
distinguishing the signs of disease from each other and from those of 
health — Other distinctions than those of intensity, pitch, and quality — 
The analytical method of the study of percussion and auscultation — 
The significance of the signs as regards the physical conditions which 
they severally represent — Morbid conditions, not individual diseases, 
represented by the morbid signs — Regional divisions of the chest — 
Anatomical relations of the regions severally to the parts within the 
chest. 

Physical Exploration. 

The physical exploration of the chest embraces six 
different methods, namely : percussion, auscultation, 
inspection, palpation, mensuration, and succussion. 
Of these, percussion and auscultation, dealing with 

2 



14 INTRODUCTION. 

sounds, involve the sense of hearing. In percussion, 
the sounds are produced by striking upon the walls 
of the chest; in auscultation, they are caused by acts 
of breathing, speaking, and coughing. 

The sounds in percussion and auscultation are, 
1st, normal or healthy sounds, being produced when 
there is no disease of the chest; and, 2d, abnormal 
or morbid sounds, being produced when the chest is 
the seat of disease. The sounds, healthy and morbid, 
constitute what are known as physical signs. Fre- 
quently, for the sake of brevity, the term signs, 
without the word physical, is used to denote these 
sounds. Conventionally, physical signs, or signs, 
are terms employed in a sense of contradistinction 
from the term symptoms. The signs are distin- 
guished, of course, as normal or healthy and abnor- 
mal or morbid. 

The sounds which constitute signs represent cer- 
tain physical conditions pertaining to the chest. 
The normal or healthy signs represent physical con- 
ditions existing when the organs are not affected by 
disease; the abnormal or morbid signs represent 
physical conditions which are deviations from, those 
of health, being incident to the various diseases of 
the chest. The physical conditions represented by 
signs may be distinguished as normal or healthy, 
and abnormal or morbid conditions. 

The representation of healthy and morbid phy- 
sical conditions by certain healthy and morbid signs 
is established by having ascertained a constancy of 
association. of the signs with the conditions. This 
constancy of association is ascertained by observa- 
tion or experience. The sounds which are constantly 



PHYSICAL EXPLORATION. 15 

obtained by percussion and auscultation in health 
are thereby established signs of healthy conditions, 
and the sounds which are only obtained in cases of 
disease are thereby established signs of morbid con- 
ditions. Our knowledge of certain sounds as the 
signs of certain physical conditions can have no re- 
liable basis other than the constancy of the connec- 
tion of the former with the latter. This constancy 
of connection is determined by the study of the 
sounds during life and examination of the organs 
after death. The existence of certain conditions is 
not to be inferred from the characters of certain 
sounds until the connection of the sounds with the 
conditions has been ascertained by experience ; then, 
and then only, are the sounds to be reckoned as 
signs of these conditions. So, also, it is not to be 
inferred from certain physical conditions found after 
death, that certain sounds must have been produced 
during life, until the connection between the condi- 
tions and the sounds has been ascertained by expe- 
rience. In other words, our knowledge of signs as 
representing physical conditions, can rest on no other 
than a purely empirical foundation. 

Our knowledge of the signs representing the phy- 
sical conditions in health and disease, thanks to the 
labors of Laennec and of those who have followed in 
his footsteps, has been brought to great perfection. 
The practical object of this knowledge is to determine 
by means of percussion and auscultation, together 
with the other methods of exploration, the existence 
of either healthy or morbid physical conditions, and 
to discriminate the latter from eacli other ; that is 
to say, the practical object is diagnosis. The signs 



16 INTRODUCTION. 

now known to represent physical conditions, healthy 
and morbid, taken in connection with symptoms and 
pathological laws, render, for the most part, the 
diagnosis of diseases of the chest easy and positive. 
Hence, it becomes the duty of the medical student 
and practitioner to give to percussion and ausculta- 
tion attention sufficient, at least, for their practical 
application to the diagnosis of the diseases commonly 
met with in medical practice ; and this duty is the 
more imperative because it involves neither peculiar 
difficulties nor great labor. In entering upon the 
undertaking, it is important to consider the require- 
ments for the successful study of this province of 
practical medicine. These requirements relate to: 
1st, the anatomy and physiology of the chest; 2d, 
the morbid physical conditions incident to the dif- 
ferent diseases of the chest ; 3d, the distinctive 
characters of healthy and morbid signs ; and 4th, the 
significance of the signs as regards the physical con- 
ditions which they severally represent. 

Anatomy and Physiology of the Chest. 

The necessity of a certain amount of knowledge 
of the anatomy and physiology of the chest, as a re- 
quirement for the study of percussion and ausculta- 
tion, together with the other methods of physical 
exploration, is too obvious to need any discussion. 
The physical conditions of health must be known 
as preparatory for appreciating the physical condi- 
tions of disease. It would be absurd to think of 
studying the latter until the former are known. 
The student, therefore, who is not acquainted with 
the anatomy and physiology of the chest, must defer 



ANATOMY AND PHYSIOLOGY OF CHEST. 17 

entering upon the study of physical diagnosis until 
this requirement is fulfilled. Familiarity with the 
morbid physical conditions is necessary ; and for the 
advanced medical student or the practitioner, it is 
advisable to refresh the memory with a reviewal of 
certain anatomical and physiological points before 
beginning the study of percussion and auscultation. 
These points, relating especially to the physical con- 
ditions of health, cannot be considered in this work. 
A simple enumeration of them can only be intro- 
duced, the reader being referred for details to trea- 
tises on anatomy and physiology. 

Important anatomical conditions relate to the 
bones of the chest, namely, the general conformation 
of the thorax ; the differences in respect of the obli- 
quity of the ribs, from above downward ; the direc- 
tion of the costal cartilages, their connection with 
the sternum, and the angles formed by the junction 
of the ribs and cartilages ; the differences in width 
of the intercostal spaces in the upper, middle, and 
lower portions of the anterior, lateral, and posterior 
aspects of the thorax, together with the relations of 
the scapula and clavicle. The relative thickness of 
the muscular covering of the chest in different situa- 
tions is to be considered, and, in women, the varying 
size of the mammas. The attachments of the dia- 
phragm to the thoracic walls, and its relations to the 
organs below, as well as above it, are points of im- 
portance. 

Important physiological conditions relate to the 
parts which the ribs, costal cartilages, sternum, and 
diaphragm severally play in the movements of res- 
piration. The differences, in respect of these move- 

9* 



18 INTRODUCTION". 

ments, in tranquil and in forced breathing; the 
contrast between the two sexes, and between early 
and advanced life are points to be studied. Other 
points are, the frequency of the respiration in health, 
and the relative duration, rapidity, and force of the 
inspiratory and the expiratory movements. 

Numerous anatomical and physiological points 
pertain to the organs within the chest. The more 
important of these, relating to normal physical con- 
ditions, are the following: 1st, as regards the lungs, 
the connections of the pleura, and the smoothness 
of the pleural surfaces in contact with each other ; 
the relations of the apex and base of each lung to 
the chest-walls, and the differences of the two lungs 
in this respect ; the relative spaces occupied respec- 
tively by the two lobes of the left, and the three 
lobes of the right lung ; the situation of the inter- 
lobar fissures in either side on the posterior, lateral, 
and anterior aspects of the chest ; the arrangement 
of the air vesicles, pulmonary lobules, and the dif- 
ferent sized intra-pulmonary bronchial tubes; the 
expansion of the air vesicles, and the movement of 
the current of air from larger to smaller bronchial 
tubes in the act of inspiration, the vesicles diminish- 
ing: in size, and the current of air moving from 
smaller to larger tubes in the act of expiration; the 
difference in respect of the relative proportion of air 
and solids at the end of inspiration and at the end 
of expiration; the extent to which the volume of 
the lungs may be diminished by a forced act of 
expiration, and increased by a forced act of inspira- 
tion ; the relations of the apices to the subclavian 
arteries, and the variable extent to which the apex 



ANATOMY AND PHYSIOLOGY OF CHEST. 19 

rises on either side above the clavicle. 2d, as re- 
gards the larynx, trachea, and the bronchial tubes 
without the lungs, the anatomy and physiology of 
the vocal chords, of the muscles concerned in the 
movements of respiration and of phonation, with the 
relations of each to the recurrent laryngeal nerve; 
the size of the rima glottidis in youth, after puberty, 
and relatively in the two sexes; the difference in 
the amount of areolar tissue above the vocal chords 
in children and in adults; the situation of the tra- 
chea, and the point of its bifurcation ; the length, 
direction, and size of the two primary bronchi con- 
trasted with each other, and the secondary branches 
which penetrate the lungs. 3d, as regards the heart, 
the boundaries of the space which it occupies — that 
is, of the precordial space ; the relations of the aorta 
and pulmonic artery to the walls of the chest, the 
portions of the precordial space in which the heart 
is covered and uncovered by lung; the situations of 
the auricles and ventricles respectively ; the rela- 
tions of these to each other, and the arrangements 
of the valves ; the currents of blood through the 
orifices within the heart, and the relations of each 
of these to the heart-sounds ; the rhythmical succes- 
sion of these sounds, and the differences which dis- 
tinguish each from the other in respect of loudness, 
duration, tone, quality, extent of diffusion, and the 
situation in which each has its maximum of inten- 
sity; the mechanism of these sounds, and the situa- 
tion of the apex-beat. 

The foregoing are the anatomical and physiologi- 
cal points which especially claim attention with 
reference to normal physical conditions preparatory 



20 INTRODUCTION. 

to entering on the study of abnormal physical con- 
ditions represented by the signs furnished by per- 
cussion and auscultation, together with the other 
methods of physical exploration. 

The Physical Conditions Incident to the Different Diseases 
of the Respiratory System. 

The numerous physical conditions incident to 
different diseases must be known, for it is the imme- 
diate object of percussion, auscultation, and the other 
methods of exploration, to ascertain either the exist- 
ence or the absence of these conditions. Knowledge 
of all the important conditions which are deviations 
from those of health, and the relations of each to 
different diseases, is, therefore, an essential require- 
ment. 

Deviations from the normal conformation of the 
chest, and the various abnormal movements of respi- 
ration, belong properly among the physical signs 
obtained by inspection, palpation, and mensuration. 
For the most part, these signs represent morbid 
physical conditions within the chest. Certain con- 
ditions relating to the pleura are accumulations of 
liquid, serous or purulent, within the pleural sac. 
The quantity of liquid may be large enough to com- 
press the lung into a solid mass, and to enlarge the 
affected side, at the same time restraining or annul- 
ling the respiratory movements ; the chest on the 
affected side, then, will contain only lung solidified 
by compression and liquid. In other cases the 
quantity of liquid is either small, moderate, or con- 
siderable, the lung, then, containing a lessened quan- 



DISEASES OF RESPIRATORY SYSTEM. 21 

tity of air, and its volume diminished in proportion 
to the amount of liquid. These conditions are inci- 
dent to simple pleurisy with effusion, pyothorax or 
empyema, and hydrothorax. 

The pleural surfaces, in cases of pleurisy, may be 
more or less covered with recent lymph, and, when 
not separated by the presence of liquid, they do not 
move upon each other smoothly and noiselessly. 
The friction of the opposed surfaces is still more 
productive of audible and sometimes tactile signs 
after the absorption of liquid, when the exuded 
lymph has become more adherent and dense than 
when it is recent. 

The presence of air in the pleural space, either 
alone or with more or less liquid, in pneumothorax, 
may compress the lung into a solid mass, also di- 
lating the affected side, and restraining or annulling 
its movements; and the air, with or without liquid, 
when not in sufficient quantity to produce these 
effects, may diminish more or less the volume of the 
lung and the amount of air in the pulmonary vesi- 
cles. These conditions give rise to characteristic 
physical signs. The perforation of lung, usually 
existing in cases of pneumothorax, occasions addi- 
tional signs which are characteristic. 

Solidification of lung is an important physical 
condition incident to several diseases, irrespective of 
the condensation just referred to caused by the com- 
pression of liquid or air in the pleural sac. Complete 
consolidation of an entire lobe, or of two and even 
three lobes, exists in the second stage of lobar pneu- 
monia. Certain physical signs are found to represent 



22 INTRODUCTION. 

this condition of complete solidification. The differ- 
ent degrees of solidification, namely, slight, moderate, 
and considerable, occur during the stage of resolu- 
tion in cases of pneumonia, and these gradations are 
severally represented by well-defined characters 
pertaining to physical signs. Solidification, circum- 
scribed, forming nodules which vary in degree and 
in the extent of June: affected, occurring either in 
one situation or more or less numerous, situated in 
the upper, lower, or middle portion of the lung, either 
on one side or on both sides, exists in phthisis, in 
broncho-pneumonia or collapse of pulmonary lobules, 
in hydatids, in hemorrhagic infarctus or embolic 
pneumonia, in pulmonary gangrene, and in carcinoma. 
It exists, greater or less in degree and more or less 
extended, in interstitial pneumonia. In these differ- 
ent connections the existence of solidification, its 
degree and extent, its limitation to one situation or 
its existence at different points, are determinable by 
means of physical signs. 

A physical condition the opposite of solidification 
is an abnormal accumulation of air within the air 
vesicles of the lungs. This is incident to pulmonary 
or vesicular emphysema, arising from a morbid 
dilatation of the air vesicles. The permanent expan- 
sion and increased volume of the upper lobes in some 
cases of this disease, occasion a characteristic defor- 
mity of the chest, together with certain deviations 
from the normal movements of respiration, which 
are also characteristic. This condition is represented 
by distinctive signs furnished by percussion and 
auscultation. Interstitial emphysema, that is, the 
extravasation of air in the areolar tissue, or inter- 



DISEASES OF EESPIEATOEY SYSTEM. 23 

lobular emphysema, in like manner gives rise to 
signs furnished by these methods of exploration. 

The presence of a viscid exudation within the air 
vesicles and bronchioles, is a morbid physical condi- 
tion incideut to vesicular pneumonia, especially in 
its first stas;e, ao-o'lutinatino- the walls of the cells and 
bronchioles, which may be brought into contact or 
close proximity at the end of the act of expiration. 
The separation of the walls thus agglutinated, in 
the act of inspiration, gives rise to an auscultatory 
sign (the crepitant rale) which is diagnostic of vesic- 
ular, in distinction from interstitial, pneumonia, 
known also as lobar and croupous pneumonia. 

An accumulation of serum within the air vesicles 
constitutes the condition called pulmonary oedema. 
This condition gives rise to signs furnished by per- 
cussion and auscultation. 

Liquid within the bronchial tubes (serum, pus, 
blood, or thin mucus) is a condition incident to 
pulmonary oedema, abscess either of the lung or 
situated elsewhere and evacuating through the bron- 
chial tubes, phthisis, bronchorrhagia,pneumorrhagia, 
bronchorrhcea, and bronchitis. The passage of air 
through the different varieties of liquid in the tubes, 
causes bubbling sounds which are appreciable in 
auscultation. The apparent size of the bubbles 
(coarseness or fineness) denotes the size of the tubes 
in which they are produced, and the pitch of the 
bubbling sounds denotes either solidification or 
otherwise of the pulmonary substance surrounding 
the tubes in which the bubbles are produced. Bub- 
bling sounds more intense and on a larger scale are 
caused by the presence of liquid within the trachea 



24 INTRODUCTION. 

and larynx, known as the tracheal rales or the death 
rattle. 

Diminished calibre of the bronchial tubes within 
the lungs, either localized, or diffused, is a condition 
due to the presence of tenacious mucus, and the 
swelling of the mucous membrane in cases of bron- 
chitis. In cases of so-called capillary bronchitis the 
condition may involve an alarming degree of ob- 
struction. The same condition is incident to bron- 
chial spasm in asthma, occasioning in this disease 
great suffering, but without immediate danger. The 
condition is represented by auscultatory signs which 
enable the auscultator to differentiate the obstruc- 
tion due to capillary bronchitis from that due to 
bronchial spasm. Permanent obliteration of more 
or less of the bronchial tubes is an occasional condi- 
tion. 

Obstruction of a bronchial tube, either within 
or without the lung, is a condition involving the 
loss of respiratory sound within the area of the 
bronchial branches and vesicles not receiving air in 
consequence of the obstruction. The obstruction 
may be temporary, being caused by a plug of mucus 
of sufficient size to prevent the passage of air ; the 
condition is then incident to bronchitis. One of 
the primary bronchi may be obstructed temporarily 
by a plug of mucus ; and obstruction of the larynx 
in childhood thus produced may be sufficient to 
cause death by suffocation. The inhalation of for- 
eign bodies is another cause of obstruction within 
the larynx, trachea, or bronchi. A primary bronchus 
or the trachea may be pressed upon by an aneurismal 
or other tumor, and, in this way, more or less obstruc- 



DISEASES OF RESPIRATORY SYSTEM. 25 

tion to the passage of air is produced. However 
produced, the situation of the obstruction and its 
degree are, in general, determinable by means of 
auscultatory signs. 

Dilatation of bronchial tubes occasions two physi- 
cal conditions differing as regards their auscultatory 
signs, namely, 1st, an enlargement of greater or less 
extent, the tubes preserving their cylindrical form; 
and 2d, a sacculated enlargement. The former occurs 
generally in connection with solidification around 
the tubes from hyperplasia of the areolar tissue, and 
is thus incident to interstitial pneumonia. The latter 
may give rise to signs which represent, pulmonary 
cavities. 

Sacculated dilatations of bronchial tubes, and the 
cavities incident to phthisis, pulmonary abscess, and 
circumscribed gangrene of lung, are represented by 
well-marked and highly distinctive signs furnished 
by percussion and auscultation. The signs denote 
either that cavities have flaccid walls which col- 
lapse in expiration, and expand in inspiration, or 
that, owing to solidification of lung, they remain 
open in both acts of respiration. 

More or less of the space within the chest, which, 
normally, is occupied by lung, may be encroached 
upon by aneurisms or other intra-thoracic tumors. 
This is a physical condition giving rise to notably 
morbid signs furnished by percussion and ausculta- 
tion. 

Finally, an extremely rare morbid physical con- 
dition is the presence of more or less of the hollow 
viscera of the abdomen within the chest, in conse- 



26 INTRODUCTION. 

quence of a congenital deficiency in the diaphragm, 
constituting diaphragmatic hernia. 

The foregoing morbid physical conditions relate 
to the respiratory system. Those relating to the 
heart are deferred, in order that they may precede 
more immediately an account of the signs of cardiac 
disease. As a requirement for the study of morbid 
physical signs, the foregoing morbid physical condi- 
tions must be understood and memorized. To assist 
the student in the latter, a summary of these condi- 
tions is appended. 

Summary of Morbid Physical Conditions Incident to 
Diseases of the Respiratory System. 

1. An accumulation of liquid, serous or purulent, 
sufficient to fill the affected side of the chest, and some- 
times causing more or less enlargement. 

2. An accumulation of liquid partially filling the 
affected side of the chest, the quantity being either small, 
moderate, or considerable. 

3. Exudation of lymph on the pleural surface. 

4. Air with liquid within the pleural cavity, and per- 
foration of lung. 

5. Air without liquid in the pleural cavity, and perfo- 
ration. 

6. Solidification of lung, either complete or approxi- 
mating to completeness. 

7. Solidification of lung slight or moderate in degree. 

8. Dilatation of the air vesicles involving within them 
an abnormal accumulation of air. 

9. Extravasation of air within the pulmonary areolar 
structure. 



HEALTHY AND MORBID SIGNS. 27 

10. Viscid exudation within the air vesicles and the 
"bronchioles. 

11. Liquid in the air vesicles. 

12. Liquid (mucus, serum pus, or blood) within bron- 
chial tubes of large, medium, or small size. 

13. Liquid within bronchial tubes of minute size. 

14. Obstruction of the pulmonary bronchial tubes by 
mucus, swelling of the mucous membrane, and spasm of 
the bronchial muscular fibres. 

15. Obstruction of larynx, trachea, or bronchi exterior 
to the lungs, by plugs of mucus or foreign bodies 

16. Obstruction of the trachea or a primary bronchus 
by aneurismal or other tumors. 

IT. Dilatation of bronchial tubes, cylindrical or saccu- 
lated. 

18. Pulmonary cavities. 

19. Tumor within the chest. 

20. Diaphragmatic hernia. 

The Distinctive Characters of Healthy and Morbid Signs. 

For the practice of percussion and auscultation, 
it is essential to be able to recognize the signs 
severally which represent the different physical con- 
ditions in health and disease. It is essential to dis- 
tinguish the morbid from the healthy signs, and to 
discriminate from each other the signs of disease. 
This recognition and discrimination of signs require 
a knowledge of the distinctive characters belonging 
to each of them. In entering upon the' study of the 
signs, therefore, it is a necessary requirement to 
know whence their distinctive characters are de- 
rived. To this point of inquiry the attention of the 
student is now invited. 



28 INTRODUCTION. 

The signs being sounds, they are to be recognized 
and discriminated in the way in which we practi- 
cally recognize and discriminate other sounds. It 
is not necessary, in order to do this, to study the 
science of acoustics. In becoming familiar with 
other sounds, for example, musical notes produced 
by different instruments, or the varieties of the 
human voice, we do not have recourse to that science. 
It suffices for all practical purposes to contrast the 
sounds, obtained by percussion and auscultation, 
with reference to very simple and obvious differences ; 
and, yet, it is necessary to understand very clearly 
in what these differences consist, or, in other words. 
the sources of the distinctive characters of these 
sounds. The more important of the differences be- 
tween the sounds obtained by percussion and auscul- 
tation relate to intensity, pitch, and quality. The 
distinctive characters of most of the signs are derived 
from these three sources. In becoming practically 
acquainted with the signs, they are to be contrasted 
as regards intensity, pitch, and quality, precisely as 
we would bring other sounds into contrast in these 
three aspects. The distinctive characters of the 
signs, severally, are especially derived from their 
differences in these respects. The distinctions ex- 
pressed by the terms intensity, pitch, and quality, 
are, therefore, to be made clear. 

Differences in the intensity of sounds are easily 
understood. One sound is more intense than another 
sound when it is simply louder, and varying degrees 
of intensity are expressed by such terms as feeble or 
weak and loud, to which may be prefixed adjectives 



HEALTHY AND MORBID SIGNS. 29 

of quality, like very, moderate, etc. This is all that 
need be said with reference to the first of the three 
aspects under which sounds are contrasted. It will 
be seen hereafter that intensity is an essential ele- 
ment in the distinctive characters of certain of the 
signs. 

Differences in the pitch of sounds are easily under- 
stood by those who have given any attention to 
music. The differences are expressed by the terms 
high and low, to which may be prefixed words denot- 
ing a greater or less degree of highness or lowness. 
A nice appreciation of variations in the pitch of mu- 
sical notes, requires what is known as a " musical 
ear ;" but a very nice appreciation is not essential 
in comparing, as regards pitch, the sounds studied 
in percussion and auscultation. For the most part, 
these sounds are not musical notes ; nevertheless, 
differences in pitch are readily perceived. A musi- 
cal ear is undoubtedly an advantage in readily dis- 
tinguishing differences in pitch ; but by no means a 
sine qua non. For those who have given no attention 
to music, some difficulty may be at first experienced 
in judging correctly of differences in this aspect; 
but the difficulty disappears after a little practice. 
Differences in pitch now enter pretty largely into 
the distinctive characters of physical signs; but by 
Laennec, and those who immediately followed him, 
comparatively little attention was paid to the study 
of the signs in this aspect. The writer was led to 
engage in this study a quarter Of a century ago, 
and hereafter in giving an account of the different 

O CD 

signs he will claim to have been the first to have 

3* 



30 INTKODUCTIOX. 

clearly indicated certain characters derived from this 
source. 1 

Differences relating to quality are apt, at first, to 
be confounded with those relating to pitch ; hence 
the distinction between pitch and quality must be 
clearly understood. "We may say of the quality of 
a sound, that it embraces whatever is not embraced 
in the terms intensity and pitch. This is true as a 
general statement. The sense of the term quality, 
in distinction from intensity and pitch, may be most 
readily made clear by an illustration. Let it be 
supposed that we hear the notes of an instrument 
which is unseen — the performer, for example, being 
in another room. We recognize at once the instru- 
ment by the notes, provided it be one with which 
we are familiar, such as a violin, a flute, a clarionet, 
etc. We do not need to see the instrument ; we 
recognize it by the sounds. I^ow, how do we recog- 
nize it ? Certainly not by the intensity of the 
sounds ; it matters not whether these be loud or 
weak, so that we hear them. Certainly not by the 
pitch ; for if a piece of music be performed, we get 
both high and low notes. We recognize the instru- 
ment by the quality of the sounds. Each musical 
instrument, owing to its peculiarity of construction, 
yields sounds which are peculiar to it; and after we 
have become familiar with the quality of sounds 
peculiar to any instrument, we immediately thereby 
recognize it. Precisely in the same way we may 

1 Vide Prize Essay on " Variations of Pitch in Percussion and 
Respiratory Sounds, and their Application to Physical Diag- 
nosis." Transactions of the American Medical Association, 
1852. 



HEALTHY AND MORBID SIGNS. 31 

recognize certain sounds produced by percussion and 
auscultation in health and disease. The signs differ 
in quality according to the physical conditions which 
they severally represent ; and differences in quality 
will be found hereafter to constitute essential and 
obvious distinctions by which the signs of health 
and disease are recognized and discriminated. This 
is a source of some of the most distinctive of the 
characters of some of the physical signs. 

Of the peculiar quality of any particular sound 
one can form no definite idea otherwise than by 
direct observation. That is to say, no one could 
describe to another the peculiar quality of a particu- 
lar sound so that it would be clearly apprehended 
without the sound having been heard. Imagine 
the attempt to describe the sound of a violin to a 
person who had never listened to the notes from that 
instrument — it would be impossible to give a cor- 
rect idea of it in language. The only way in which 
an approximative idea could be conveyed in words, 
would be by comparing the quality to that of some 
other instrument to the notes of which there was 
some resemblance — that is, by analogy. To attempt 
to describe the quality of sounds to one who had 
never heard them, would be like describing colors 
to one blind. It will be seen hereafter that the 
quality of certain sounds obtained by percussion and 
auscultation is peculiar to them, and their distinc- 
tive characters in this aspect can be known only by 
direct observation; they cannot be learned by meaus 
of any verbal description, nor by any comparisons — 
that is, by analogy. 

Appreciable variations in the quality of sounds 



32 INTRODUCTION. 

are infinite. This may be illustrated by the human 
voice. Almost every person may be recognized from 
a peculiar quality of the voice by one who is familiar 
with it ; and the voices of thousands of persons, if 
compared, would present shades of difference — in 
fact, as is well known, it is extremely rare for the 
voices of any two persons to be so nearly identical 
in quality that they cannot be distinguished from 
each other. As the diversities in quality of different 
sounds cannot be described, so they can only be 
designated by names which are significant from cer- 
tain resemblances. Terms based on analogies which 
are used to denote qualities of the sounds furnished 
by percussion and auscultation are the following: 
rough, harsh and rude, soft, blowing, hollow, musi- 
cal, moist, dry, bubbling, gurgling, crackling, click- 
ing, rubbing, grating, creaking, tubular, cracked 
metal, sibilant or whistling, sonorous or snoring. 
All these names owe their significance to resem- 
blances to other sounds. One sound furnished both 
by percussion and auscultation has a quality which 
is sui generis, and the term used to distinguish it is 
derived from its source, namely, the vesicular reso- 
nance, and the vesicular murmur of respiration. 

In addition to intensity, pitch, and quality as 
sources of the distinctive characters of the signs 
furnished by percussion and auscultation, there are 
some other points of difference; namely, the dura- 
tion of certain sounds, their continuousnessor other- 
wise, their apparent nearness to or distance from the 
ear, and their strong resemblance to particular sounds, 
such as the bleating of the goat, the chirping of birds, 



HEALTHY AND MORBID SIGNS. 33 

etc. These points of difference are of lesser impor- 
tance, the more important by far relating to intensity, 
pitch, and quality. 

The study of the different sounds furnished by 
percussion and auscultation, with reference to dis- 
tinctive characters relating especially to intensity, 
pitch, and quality, distinct signs being determined 
from points of difference as regards these characters, 
may be distinguished as the analytical method. It 
may be so distinguished in contrast with the deter- 
mination of signs by deductively taking as a stand- 
point either the physical conditions incident to 
diseases or the sounds. If we undertake to decide, 
a priori, that certain sounds must be produced by 
percussion and auscultation when certain conditions 
are present, we shall be led into error; and so, equally, 
if we undertake to conclude from the nature of the 
sounds that they must represent certain conditions. 
The only reliable method is to analyze the sounds 
with reference to differences relating especially to 
intensity, pitch, and quality, and to determine differ- 
ent signs by these differences, the import of each of 
the signs being then established by the constancy of 
association with physical conditions. It is by this 
analytical method only that the distinctive characters 
of signs can be accurately and clearly ascertained. 
This is to be borne in mind by the student in physi- 
cal exploration. He is to become acquainted with 
the different signs, and to recognize them in practice, 
by acquiring a knowledge of the distinctive char- 
acters of each, as derived mainly from differences 
relating to intensity, pitch, and quality. The indi- 



34 INTRODUCTION. 

viduality of the signs, severally, can rest on no other 
solid basis. 

The Significance of the Signs as regards the Physical 
Conditions which they severally represent. 

Knowledge of the significance of the physical signs 
is the complemental requirement in the study of per- 
cussion and auscultation. For the successful employ- 
ment of these methods, in addition to the recogni- 
tion of each sign by its distinctive characters, must 
be known its significance, that is, the physical con- 
dition which it represents. In this respect the signs 
may be compared to the substantives in language, 
each having a definite signification. The signs 
furnished by these methods may be said to constitute 
a language with a very small vocabulary ; or taking 
as the stand-point the things signified, the different 
physical conditions manifest or express themselves 
by means of the signs. 

It is to be noted that the significance of the mor- 
bid signs relates immediately, not to diseases, but to 
the physical conditions incident thereto. Very few 
signs are directly diagnostic of any particular dis- 
ease. They represent conditions not peculiar to one 
but common to several diseases. Thus, solidification 
of lung exists in pneumonia, phthisis, pleurisy with 
effusion, collapse, and pulmonary cancer, and certain 
signs tell us that this condition exists, together with 
its situation, its degree, and its extent. With this 
information the diagnosis of the disease is made by 
connecting with it pathological laws, together with 
the history and symptoms. The student in physical 
exploration should by no means imagine that, for 



KEGIONAL DIVISIONS OF THE CHEST. 35 

the diagnosis of diseases, exclusive reliance is to be 
placed on the signs"; they are always to be taken in 
connection with pathological laws, the history, and 
the symptoms. Disconnected from these, the signs 
would often lead to error, and it is no disparagement 
to physical diagnosis that its reliability depends 
on other facts than those which belong exclusively 
to it. 

To repeat a statement already made more than 
once, the significance of the signs, as regards the 
conditions which they severally represent, is based 
on the constancy of their association with the latter, 
our knowledge of this association being derived from 
examinations during life and after death. 

Regional Divisions of the Chest. 

Before entering on the study of physical explora- 
tion, the student should become acquainted with the 
divisions of the surfaces of the anterior, posterior, 
and lateral aspects of the chest into circumscribed 
spaces which are called regions. These divisions, 
deriving their boundaries and names from their 
anatomical relations, are sufficiently simple. 

Anteriorly the chest is divided into regions as 
follows : The supra or post-clavicular, the clavicular, 
the infra-clavicular, the mammary, and the infra- 
mammary regions. The supra- or post-clavicular re- 
gion" extends from the clavicle upward a short dis- 
tance, corresponding to the variable height to which 
the lung rises above this bone. The clavicular re- 
gion embraces the space occupied by the clavicle. 
The infra-clavicular region embraces the space be- 
tween the clavicle and the third rib. The mammary 



36 INTRODUCTION. 

region is bounded above by the third and below by 
the sixth rib, and the infra-mammary region is the 
portion of the chest below the sixth rib. 

Posteriorly the divisions are into the scapular, the 
infra-scapular, and inter-scapular regions. The scap- 
ular region is the space occupied by the scapula, and 
is divided by the spinous ridge into the upper and 
lower scapular space. The infra-scapular region is 
the portion below a horizontal line at the lower 
angle of the scapula. The inter-scapular region is 
the space between the posterior margin of the scap- 
ula and the spinal column. 

Laterally there are two regions, namely, the axil- 
lary and the infra-axillary. The axillary region is 
the space above a horizontal line extending from the 
lower border of the mammary region, i. <?.,the sixth 
rib. The infra-axillary region is the portion below 
the axillary region. 

The portion of the anterior surface occupied by 
the sternum is divided into the upper and the lower 
sternal region, the space above the sternal notch be- 
ing the supra-sternal region. 

In order to become familiar with the foregoing: 
regional divisions, it is recommended to the student 
to delineate them with ink on the chest of the living: 
subject or a cadaver. 

It is advisable to study sections, extending from 
the surface to the centre of the chest, corresponding 
to the different regions, so as to become familiar 
with the relation of each section to the parts con- 
tained within it. An enumeration of the more 



REGIONAL DIVISIONS OF THE CHEST. 37 

important of the anatomical relations of the differ- 
ent regions is as follows: — 

1. Supra-clavicular Region. — This is relative to 
the upper extremity or apex of the lung which rises 
above the clavicle in different persons from half an 
inch to an inch and a half. The height is generally 
greater on one side, and this side is usually the left. 

2. Clavicular Region. — A small portion of the lung 
at or near the apex is contained in the section cor- 
responding to this region. 

3. Infra-clavicular Region. — The parts situated here 
are the upper portion of the lung, the lower part of 
the trachea, with its bifurcation, and the primary 
bronchi. The bifurcation is on a level with the 
second rib. The differences between the tw r o pri- 
mary bronchi, as regards direction, size, and length, 
are important points in the study of this section. 

4. Mammary Region. — The differences between 
the two sides in the sections corresponding to this 
region are important. These differences relate espe- 
cially to the prsecordia, and are especially involved 
in the physical diagnosis of enlargement of the heart. 
The commencement of the interlobar fissures are in 
this region. On the left side the fissure is between 
the fourth and fifth ribs. On the right side the 
fissure between the upper and middle lobes begins 
at the fourth costal cartilage, and between the mid- 
dle and lower lobes a short distance below. The 
situations of the fissures, however, differ consider- 
ably during the acts of inspiration and expiration. 

5. Infra-mammary Region. — This region differs in 
its anatomical relations considerably on the two sides 
of the chest. On the right side the liver pushes 

4 



38 INTRODUCTION. 

upward the diaphragm nearly or quite to the upper 
boundary, namely, the sixth rib. On the left side 
the section corresponding to the region embraces, 
together with the anterior portion of the lower lobe 
of the lung, portions of the stomach, spleen, and the 
left lobe of the liver. The variable volume of the 
stomach at different times occasions considerable 
variations in the relative spaces occupied by these 
different parts. 

6. Suprasternal Region. — This region is in rela- 
tion to the trachea. 

7. The Upper Sternal Region. — The bifurcation of 
the trachea is beneath the sternum at the centre of 
a line connecting the second ribs. Below this line 
the lungs on the two sides are nearly in contact at 
the mesial line, covering the primary bronchi. 

8. Lower Sternal Region. — The sternum in this 
region covers a large portion of the right and a little 
of the left ventricle. 

9. Scapular Region. — The section corresponding to 
this region contains the posterior portion of the 
upper lobe and a portion of the upper part of the 
lower lobe of the lung. At the upper part of the 
lower scapular space, terminates the fissure separat- 
ing the upper and the lower lobe. The line of this 
fissure pursues an oblique course to the fourth or 
fifth rib on the anterior aspect of the chest. 

10. Infra-scapular Region. — On the right side the 
lung extends from the upper boundary of this region 
to the eleventh rib, the liver rising to the latter 
point. On the left side the section contains a portion 
of the spleen. 

11. Inter-scapular Region. — The trachea extends 



REGIONAL DIVISIONS OF THE CHEST. 39 

in this section to the fourth dorsal vertebra, where 
it bifurcates. Below this point, on the two sides, 
are situated the primary bronchi. 

12. Axillary Region. — The section corresponding 
to this region contains a portion of the upper lobe 
with large bronchial tubes. 

13. Infra-axillary Region. — This is in relation to 
the upper part of the liver on the right side, and on 
the left side to a portion of the spleen and stomach, 
the remainder of the section occupied by lung. 

It is recommended to the student to become 
familiar with the sections corresponding to the dif- 
ferent regions, by dissections for this purpose, and 
the study of anatomical illustrations. 

Asking the student's careful attention to the in- 
troductory considerations which have been presented, 
percussion and auscultation in health and disease, 
and the physical signs involved in the diagnosis of 
diseases of the respiratory system and of the heart, 
will be considered as follows: Chapter II., Percus- 
sion in Health ; Chapter III., Percussion in Disease ; 
Chapter IV., Auscultation in Health ; Chapter V., 
Auscultation in Disease ; Chapter VI., The Physical 
Diagnosis of the Diseases of the Respiratory System; 
Chapter VII., The Physical Conditions of the Heart 
in Health and Disease ; Chapter VIII., The Physical 
Diagnosis of Diseases of the Heart, and, as properly 
embraced in the scope of this treatise, Chapter IX. 
will be devoted to the Diagnosis of Thoracic Aneu- 
risms. 



CHAPTER II. 
PEKCTJSSION IN HEALTH. 

Percussion with the fingers or with a percussor and pleximeter — The nor- 
mal vesicular resonance on percussion ; its distinctive characters relat- 
ing to intensity, pitch, and quality — Variations in the characters of the 
normal vesicular resonance in different persons — Relations of the pitch 
of resonance to the vesicular quality — Tympanitic resonance over the 
abdomen — Variations of the normal resonance in the different regions 
of the chest — Enumeration of the regions in which the resonance on 
the two sides varies, and those in which it is identical in health — In- 
fluence of age on the normal resonance — Influence of the acts of res- 
piration on the resonance — Rules in the practice of percussion. 

Percussion may be performed with either the 
lingers or artificial instruments. The finders suffice 
for the study and in ordinary practice. Instruments 
are preferable only when it is desired to produce 
sounds to be heard at some distance, as in class 
illustrations, and when, from the number of patients 
to be percussed, as in dispensary or hospital practice, 
the frequent repetition of the blows renders the 
fingers tender and painful. The instruments are a 
pleximeter and a percussor. The simplest and most 
convenient pleximeter is an oval disk of ivory or 
hard India-rubber, with projecting handles or auri- 
cles, sufficiently large and roughened on their outer 
aspect, so as to be conveniently held by the fingers. 
The best percussor is a double cone of caoutchouc 
inclosed by a metallic ring, to which is attached a 
rod of metal with a wooden handle of convenient 
length, weight, and size. This instrument is very 



NORMAL RESONANCE. 41 

durable. When percussion is performed with the 
fingers, the palmar surface of one or more of those 
of the left hand should be applied to the chest, with 
pressure sufficient to condense the soft structures, 
and the blows are given with one or more of the 
lingers of the right hand bent at the second pha- 
langeal joint so as to form a right angle. In giving 
the blows, the movements should be limited to the 
wrist-joint, the ends, not the pulp, of the percussing 
fingers being brought into contact with the dorsal 
surface of the finger, or fingers, applied to the chest. 
The percussing fingers should be withdrawn instantly 
the blow is given. The type of perfect percussion 
is the movement of the hammers when the keys of 
a piano-forte are struck. The force of the percus- 
sion should never be sufficient to give pain to the 
patient ; generally either light, or moderately forcible 
blows suffice. The requisite tact in the performance 
of percussion is acquired by a little practice. 

The first object in the study of percussion is to 
become acquainted with the characters which are 
distinctive of the sound obtained thereby from the 
healthy chest. For this object the percussion may 
be made either in front in the infra-clavicular region 
of either side, or behind in the infra-scapular region, 
the sound in these situations being louder than in 
other regions. Percussion being performed, a sound 
or a resonance is produced. This sound or resonance 
is now to be analyzed with reference to characters 
derived from intensity, pitch, and quality. What 
are these characters? The intensity will depend, 
other things being equal, on the force of the blow ; 
the resonance is comparatively feeble with a slight, 

4* 



42 PERCUSSION IN HEALTH. 

and loud with a strong percussion. Other circum- 
stances affect the intensity, irrespective of the force 
of the blow, namely, the volume of ' the lung, the 
elasticity of the costal cartilages, and the thickness 
of the soft parts which cover the chest. Owing to 
these circumstances, the intensity of the resonance 
is by no means similar, in the same situation, in all 
healthy persons ; it is comparatively feeble in some 
and loud in others. There is nothing distinctive of 
this normal resonance to be derived from intensity, 
and we say, therefore, that the intensity is variable. 

What is the pitch of this normal resonance ? The 
pitch of a sound is always relative ; and, comparing 
this resonance with all the morbid signs obtained 
by percussion, it is lower in pitch. We say, there- 
fore, that the pitch of this normal resonance is low. 
The pitch, however, is found to vary in different 
healthy persons. 

What is the quality of this normal resonance ? It 
has a quality which is peculiar to it. In this respect 
it is not identical with any sound produced other- 
wise than by percussion over healthy lung either 
within or without the chest. The quality cannot, 
therefore, be learned by analogy, nor can it be de- 
scribed ; it can only be appreciated by direct obser- 
vation. The peculiar quality is due to the fact 
that the resonance is from air contained in the 
pulmonary vesicles. This arrangement causes the 
peculiar quality, just as the construction of any 
particular musical instrument causes the quality of 
tone peculiar to that instrument; hence, as it is 
convenient to give the quality a name, we call it the 
vesicular quality. This quality is not equally marked 



VARIATIONS IN NORMAL RESONANCE. 43 

in all healthy persons, being, as a rule, more marked 
in proportion to the intensity of the resonance. 

The normal resonance, then, obtained by percus- 
sion, may be thus defined : — 

A resonance of variable intensity, low in pitch 
and having a peculiar quality called vesicular. The 
word vesicular is frequently embraced in the name 
of this healthy sign ; we call it the normal resonance, 
the normal pulmonary resonance, or the normal 
vesicular resonance. The last of these names is to he 
preferred. 

The normal vesicular resonance on percussion, as 
has been seen, is not uniform in all healthy persons; 
not only is its intensity variable, but it varies in 
pitch and in the amount of vesicular qualit} T . This 
may be easily illustrated, by percussing successively 
in the same situation, and with the same force, a 
series of persons who are assumed to be free from 
disease. Is there not in this fact an obstacle in 
practically determining this healthy sign ? The fact 
occasions no embarrassment for this reason: we 
determine, in each case, that the resonance is normal 
by a comparison of the two sides of the chest, per- 
cussing in corresponding situations on the two sides 
and with the same force. There is no abstract stan- 
dard of the normal vesicular resonance, but, by com- 
paring the two sides of the chest, the standard of 
health proper to each person is obtained. The laws 
of disease are such that, for all practical purposes, 
the standard of health is in this way almost always 
available. Notwithstanding the variations within 
the range of health, the lowness in pitch and the 



44 PERCUSSION IN HEALTH. 

vesicular quality are sufficiently distinctive of this 
normal sign as compared with the morbid signs. 

The pitch of the vesicular resonance and its vesi- 
cular quality are in a uniform relation to each other ; 
that is, the conditions giving rise to the peculiar 
quality, also render the pitch low. In proportion as 
the vesicular quality is marked, the pitch is lowered, 
and, conversely, with diminution of the vesicular 
quality the pitch is relatively higher. This relation 
between the pitch and quality will be found to hold 
good in the resonance modified by disease as well 
as in health. Another relation may be here stated, 
namely, whenever, in health or disease, a tympanitic 
quality is combined with the vesicular, and in pro- 
portion as the former predominates, the pitch of the 
resonance is raised. 

The pitch and quality of the normal vesicular 
resonance may be readily illustrated by percussing 
successively over the chest and the abdomen. The 
different sections of the alimentary canal, generally 
containing more or less gas, a resonance is obtained 
by percussion over the abdomen. This resonance is, 
of course, devoid of the vesicular quality ; in contra- 
distinction to the latter its quality is called tympa- 
nitic. This tympanitic resonance is not uniform in 
all parts of the abdomen, but everywhere the quality 
is tympanitic, that is, non-vesicular, and the pitch is 
everywhere higher than that of the normal vesicular 
resonance. The tympanitic resonance over the sto- 
mach is generally high in pitch, and frequently has 
a ringing or metallic intonation. The gastric tym- 
panitic resonance, recognized by these characters, 
will be found to be involved frequently in sounds 



RESONANCE IN DIFFERENT REGIONS. 45 

produced by percussing over the chest. Gas in the 
cjecum gives a still higher pitch of resonance. Over 
the colon the resonance is lower than over the csecum 
and stomach, and it is still lower over the small in- 
testines. In all these situations, bringing the tym- 
panitic in contrast with the normal vesicular reso- 
nance, the peculiar quality of the latter and its 
lowness of pitch are rendered apparent. The term 
tympanitic resonance will be found to enter into 
the names of two of the morbid signs obtained by 
percussion. 

Having studied the characters of the normal 
vesicular resonance, and become practically familiar 
with them by percussing different healthy persons, 
the student should study the variations which this 
resonance presents in the different regions of the 
chest. In doing this he acquires more and more 
tact in the performance of percussion, and becomes 
more and more familiar with the characters in 
general of the normal vesicular resonance. 

Supra- or Post-clavicular Region. — The resonance 
here varies much in intensity in different persons. 
The vesicular quality is most marked in the central 
portions. Toward the sternal extremity the reso- 
nance acquires a tympanitic quality from the prox- 
imity to the trachea ; it becomes vesiculotympanitic, 
a term which will be applied to one of the morbid 
signs. 

Clavicular Region. — Hear the sternum the reso- 
nance is somewhat tympanitic from the proximity 
to the trachea. At the central portion the vesicular 



46 PERCUSSION IN HEALTH. 

quality is more or less marked, and the intensity is 
diminished at the acromial extremity. 

Infra-clavicular Region. — The resonance in this 
region is more intense than elsewhere, excepting 
the axillary and the infra-scapular regions. The 
vesicular quality is combined with a tympanitic 
quality toward the sternum, the latter being derived 
from the primary and secondary bronchi. As always 
when the vesicular and the tympanitic quality are 
combined, the pitch is raised. This combination in 
health and disease is recognized by the intensity, 
pitch, and quality. 

Scapular Region. — The resonance in this region is 
notably less intense than in the infra-clavicular 
region, owing to the presence of the scapula and its 
muscles. In proportion as the intensity is less, the 
vesicular quality is less marked. The resonance in 
health, however, is quite sufficient for morbid signs 
to be available in this situation. 

Inter - scapular Region. — The resonance in this 
region is weak in comparison with other regions, 
owing to the muscles which here cover the chest. 
In the upper part of the region the resonance is 
somewhat tympanitic from the relation to the 
trachea and bronchi. 

Mammary Region. — The right and the left mam- 
mary region are to be studied with reference to 
differences relating to the liver and the heart. On 
the right side, from the fourth rib downward, the 
resonance is diminished, the convex extremity of 
the liver extending up to this height. At or a 
little below the lower border of this region on the 
mammary line, that is, a vertical line passing through 



RESONANCE IN DIFFERENT REGIONS. 47 

the nipple, resonance ceases, the lower lobe of the 
right lung not extending below this point. Between 
the third and fifth ribs on this side near the ster- 
num the resonance is diminished from the presence 
of a portion of the right auricle and ventricle. On 
the left side the resonance is diminished within the 
precordial space. This space extends vertically from 
the third rib to the fifth intercostal space, and hori- 
zontally from the sternum to a point at or a little 
within the mammary line. The resonance is con- 
siderably diminished within what is called the super- 
ficial cardiac space. This space is represented by a 
right-angled triangle, the" right angle formed by a 
vertical line drawn from a point on the median line 
intersected by a horizontal line connecting the fourth 
ribs, and a horizontal line intersecting the point of 
apex beat in the fifth intercostal space; an oblique 
line drawn from the centre of the sternum on a level 
with the fourth rib and the point of apex beat forms 
the hypothenuse of the right-angled triangle. Within 
this space the heart is in contact with the thoracic 
wall. Without this space and within the preecordia 
the heart is covered with lung, and the resonance on 
percussion is less diminished. It is a useful exercise 
for the student to observe the diminution of the area 
of the superficial cardiac space by a forced inspira- 
tion, and the increase of this area by a forced expi- 
ration, as determined by percussion. Aside from 
the presence of the heart and the convex extremity 
of the liver, the resonance over the mammary is less 
than in the infra-clavicular region, being diminished 
by the pectoral muscle which varies considerably in 
bulk in different persons, and in women by the 



48 PERCUSSION IN HEALTH. 

mammary gland, the size of the latter varying very 
much in different women. The development of the 
mammse, however, is never so great as to preclude 
the useful employment of percussion in this region. 

Infra-mammary Region. — In this region, as in the 
region above it, the two sides present notable differ- 
ences owing: to the situation of organs below the 
diaphragm. On the right side, over the greater part, 
and sometimes the whole of this region, resonance is 
wanting, that is, percussion gives flatness. It is 
easy to delineate the boundary between the lower 
border of the right lung and the liver, or, as it is 
called, the line of hepatic flatness. It is also easj- to 
distinguish over this line the height to which the 
lower extremity of the liver extends, or, as it is 
called, the line of hepatic dulness. The situation of 
both these lines varies considerably in different 
healthy persons. The distance between the two lines 
is from one to ten inches. Both lines are affected 
considerably by a forced inspiration and a forced ex- 
piration. A forced inspiration depresses the line of 
flatness about one and a half inches. A forced ex- 
piration causes the line to rise from two and a half 
to five and a half inches. The distance, therefore, be- 
tween this line at the end of a forced expiration, and 
at the end of a forced inspiration varies from four to 
seven inches. With reference to the practice of per- 
cussion, as well as for the purpose of verification, 
these points should be studied. ~Not infrequently 
percussion over the right infra-mammary region 
yields a tympanitic resonance due to the distension 
with gas to the transverse colon. 

On the left side, the resonance in this region varies 



RESONANCE IN DIFFERENT REGIONS. 49 

in different persons, in the same person at different 
times, and in different portions of the region at the 
same time, the variations depending on the organs 
below the diaphragm. Flatness is caused by the 
extension of the left lobe of the liver into this region 
about ten inches to the left of the median line. 
The left portion of the region is in relation to the 
spleen, an organ which varies considerably in size 
in health as well as disease, its average dimensions 
being about four inches in length and three inches 
in width. Between the spleen and the liver lies the 
stomach, the volume of which is constantly fluctu- 
ating, owing to its varying solid, liquid, and gaseous 
contents. Distension of the stomach with gas occa- 
sions a tympanitic resonance which frequently is 
transmitted above into the mammary region in 
health as well as in disease. The space correspond- 
ing to the spleen is determined by the vesicular 
resonance above and the tympanitic resonance below, 
the latter boundary, however, not being very reliable 
on account of the ready conduction of tympanitic 
resonance for a certain distance. The distension of 
the stomach with solid or liquid contents of course 
occasions flatness. The study of the infra-mammary 
regions with reference to the variations in resonance 
arising from the relations to the organs below the 
diaphragm, is of much utility from the practice, as 
well as the knowledge, which it involves. The ex- 
ercise of endeavoring to define the boundaries of 
these different organs in healthy persons, will be of 
great service to the student in acquiring tact in per- 
cussion, and in discriminating differences in the 
sounds obtained by this method. 



50 PERCUSSION IN HEALTH. 

Sternal Regions. — In the upper sternal region, that 
is, above the lower margin of the second rib, the 
resonance is non-vesicular, being derived from air in 
the trachea above the point of bifurcation. Being 
non-vesicular, it is, of course, tympanitic, this term 
embracing all sounds which are devoid of the ve- 
sicular quality. Between the second and third ribs, 
the inner borders of the two lungs approximating, 
the resonance has a vesicular quality more or less 
marked ; but owing to the remnant of the thymus 
gland, together with adipose substance, and the 
presence of the large vessels, the resonance is not 
intense in this situation. Below the third rib the 
resonance has modifications due to the combina- 
tion of several different organs situated beneath the 
lower sternal region. On the right side of the 
mesial line is the inner border of the risen t lunsr, the 
greater part of the right and a portion of the left 
ventricle of the heart lying beneath; a portion of 
the liver extends into the lower part of this region, 
and a portion of the stomach when distended. The 
resonance thus varies in different situations, and 
often presents a mixed character. It is a useful 
exercise to endeavor to define by percussion the 
boundaries of the several organs which are here in 
juxtaposition. 

Infra-scapular Regions. — The resonance below the 
scapula is intense as compared with that over the 
scapula, and the vesicular quality is marked. The 
resonance extends to the eleventh rib which is 
the lower boundary of the lung. On the right side, 
at or near this point, is the line of hepatic flatness, 
hepatic dulness extending from one to two inches 



RESONANCE IX DIFFERENT REGIONS. 51 

above this line. The line of hepatic flatness and of 
hepatic dulness is lowered from one to two inches 
by a deep inspiration, and raised by a forced expira- 
tion. On the left side the resonance may receive a 
tympanitic quality from the presence of gas in the 
stomach. 

Lateral Regions. — In these regions the resonance is 
relatively intense, and notably vesicular. On the 
right side the line of hepatic flatness is at the eighth 
rib, hepatic dulness extending above this line as in 
front and behind. On the left side the resonance 
may be rendered somewhat dull by the presence of 
the spleen, but it oftener acquires a tympanitic 
quality from the presence of gas in the stomach. 

As has been stated, the normal vesicular resonance 
is not in all persons identical as regards intensity, 
pitch, and quality. There is, therefore, no fixed 
standard in these respects by which we can deter- 
mine whether the resonance be normal or not. The 
standard proper to each person is to be ascertained 
by a comparison of the two sides of the chest ; each 
person, in other words, furnishes his own standard 
of health. But, it is to be observed, that all the 
regions do not normally correspond in respect of the 
resouance on the two sides. In the following regions 
the resonance is notably dissimilar on the two sides: 
The mammary, the infra-mammary, the infra-axil- 
lary, and the infra-scapular. On the other hand, in 
the following regions the resonance on the two 
sides is nearly or quite identical: The supra-clavi- 
cular, clavicular and infra-clavicular, the scapular 
and inter-scapular, and the axillary. In some of 
the latter the resonance has normally some points 



52 PEECUSSION IN HEALTH. 

of disparity, and it is of practical importance to note 
the small dissimilarity which thus belongs to health. 
This statement applies especially to the infra-cla- 
vicular region, a region which, as will be seen here- 
after, is of great importance with reference to the 
signs of phthisis. In this region the resonance on the 
left side is somewhat more intense, more vesicular, 
and lower in pitch than the resonance on the right 
side ; per contra, the resonance is less intense, less 
vesicular, and higher on the right side. This dis- 
parity is observable in all persons, but is more 
marked in some than in others. The student should 
become practically familiar with this normal differ- 
ence between the two sides, and in becoming so, 
the practical experience acquired in performing 
percussion will be of use. 

The normal resonance is affected by age. In early 
life, when the costal cartilages are flexible and elas- 
tic, the resonance is more intense and lower in pitch 
than in old age when the cartilages are rigid, and 
the vesicular structure of the lung more or less 
atrophied. 

The resonance varies considerably in the different 
regions at the end of a full inspiration and at the 
end of a forced expiration. With regard to this 
disparity, the following is an extract from a work 
on physical exploration, published by the author in 
1856 :^ 

"The percussion-sound may also be found to vary 
at different periods of an act of respiration in the 
same individual. The quantity of air contained 
within the air-cells, and consequently the relative 
proportion of air and solids, are by no means equal 



INFLUENCE OF RESPIRATION. 53 

after a full inspiration and after a forced expiration. 
This difference in lung expansion may occasion an 
appreciable disparity in resonance, according as the 
percussion is made at the conclusion of a full inspira- 
tion, or a forced expiration. The disparity is not 
appreciable uniformly in different persons. This fact 
I have ascertained by noting the results of examina- 
tions made with reference to the point. When it 
does exist, it usually consists, contrary to what might 
perhaps have been anticipated, and the reverse of 
what is usually stated in works on physical explora- 
tion, in diminished resonance and elevation of pitch 
at the conclusion of inspiration. This is probably 
to be explained by the greater degree of tension of 
the lungs and thoracic walls produced by inspiration 
voluntarily prolonged and maintained^ — a condition 
presenting physical obstacles to sonorous vibrations 
more than sufficient to counterbalance the increased 
proportion of air within the cells. It is a curious 
fact, worthy of notice, that the two sides of the chest 
are not always found to be affected equally as regards 
the percussion-sound, at the conclusion of a full in- 
spiration, contrasted with that after a forced expira- 
tion. I have observed the contrast to be more 
striking on the right than on the left side; and in 
one instance on the left side, the resonance was less 
intense and somewhat tympanitic after a full inspi- 
ration, while on the right side, the opposite effect 
was produced, and the sound became quite dull after 
a forced expiration. In view of these variations in 
a certain proportion of instances incident to different 
periods of a single act of respiration, in some cases 
of disease in which it is desirable to observe great 

5* 



54 PERCUSSION IN HEALTH. 

delicacy in the correspondence of the two sides, pains 
should be taken to percuss corresponding points at 
a similar stage of respiration, and the close of a full 
inspiration is, perhaps, the period to be preferred. 
Ordinarily, the liability to error from this source is 
obviated, either by repeating a series of strokes, first 
on one side and next on the other, or by percussing 
both sides repeatedly in quick succession, in order 
mentally to obtain the average intensity and other 
characters of the sound during the successive stages 
of a respiration. The instances of disease, however, 
are exceedingly rare, in which such nicety of dis- 
crimination is important." 

Prof. Da Costa has recently, studied more fully the 
variations in this respect in the different regions in 
disease as well as in health, and he has distinguished 
this as " respiratory percussion." 1 

Rules in the Practice of Percussion. 

1. Prior to a comparison of the two sides of the 
chest, as regards the resonance on percussion, either 
in health or disease, an examination by inspection 
should be made, in order to determine whether there 
be any deviation from the normal conformation. In 
what has been stated concerning percussion in 
health, it is assumed that the chest is symmetrical. 
Want of symmetry may be due to congenital de- 
formities, and to those caused by rachitis, chronic 
pleurisy, curvature of the spine, and injuries. Any 
deviation from the normal conformation will affect 
more or less the resonance in corresponding regions 

1 Vide work on Diagnosis, fourth edition, 1876. 



RULES IX PRACTICE OF PERCUSSION. 55 

on the two sides. Dae allowance is to be made for 
want of symmetry in determining morbid signs, and 
often the existence of these cannot be determined 
with positiveness when there is considerable de- 
formity. The signs obtained by auscultation are less 
affected by want of symmetry than those obtained 
by percussion. 

2. Attention to the position of the person examined 
is important with reference to the normal symmetry 
of the chest. If the person be standing or sitting, 
the position should be upright and the shoulders 
brought to a level. A little inclination of the body 
to one side, or a depression of one shoulder, will be 
found to affect perceptibly the normal resonance, 
when the two sides are compared. If the body be 
recumbent, it should be as near as possible on a level 
plane. These conditions are indispensable for a nice 
comparison of the two sides either in health or 
disease. 

3. In making a nice comparison, the person who 
percusses should be as nearly as possible directly 
either in front or behind the person percussed. Per- 
cussion made by one standing or sitting by the side 
of the person percussed, is almost certain to produce 
an abnormal disparity. 

4. Percussion made successively on one side, and 
the other side, must be in all respects the same, in 
regard to the mode, the force of the blow, and the 
situation. A light percussion on one side, and a 
strong percussion on the other side, will, of course, 



56 PERCUSSION IN HEALTH. 

cause a disparity in the intensity of resonance. The 
percussion must be made in succession at points as 
nearly as possible equidistant from the median line, 
and from the summit or base of the chest. With 
reference to great nicety, the percussion, if made on 
the rib or intercostal space on one side, must be made 
on the rib or intercostal space on the other side. 
Great nicety of comparison also requires that, if the 
percussion be made on one side during the act of 
inspiration, it should be made on the other side 
during this act. The signs of disease, however, are 
generally so well marked, that very close attention 
to these points is not necessary. 

5. A series of blows in rapid succession (5 or 7) is 
to be preferred to one or two, in practising percus- 
sion, difference in intensity, pitch, and quality being 
thereby better appreciated. 

6. Percussion may be made lightly or forcibly, 
the former being called superficial, and the latter 
deep percussion. With light blows the resonance 
comes from the superficies of the lung, and from 
within a limited area. With forcible blows the 
resonance is from a greater depth, and a wider space. 
The results of these different modes of practising 
percussion may be illustrated within the prsecordia 
in health. Comparing the resonance over the super- 
ficial cardiac space with that in a corresponding 
situation on the right side, dulness is more marked 
wi.th light than with forcible blows, the resonance 
from the latter coming from a wider area. On the 
other hand, comparing the resonance over the deep 



RULES IN PEACTICE OF PERCUSSION. 57 

cardiac space, dulness is more marked with forcible 
than with light blows, owing to the presence of lung 
between the heart and the walls of the chest ; this 
rule is of importance in its application to percussion 
in disease. 

7. Percussion over the anterior portion of the 
chest, the person percussed leaning against a door, a 
board partition, or a lathed wall, gives an increased 
intensity of resonance. It is often useful to resort to 
this procedure in the practice of percussion in health 
and in disease. 



CHAPTER III. 

PERCUSSION IN DISEASE. 

Enumeration of the signs of disease furnished by percussion — Require- 
ments for a practical knowledge of these signs — The distinctive 
characters of, the morbid physical conditions represented by, find the 
different diseases into the diagnosis of which enter, these signs, seve- 
rally, to wit, 1. Absence of resonance or flatness; 2. Diminished 
resonance or dulness; 3. Tympanitic resonance ; 4. Vesiculo-tympanitic 
resonance; 5. Amphoric resonance; 6. Cracked metal resonance — 
Sense of resistance felt in the practice of percussion as a morbid 
sign. 

Percussion in disease furnishes signs which rep- 
resent certain of the morbid physical conditions 
incident to the different pulmonary affections ; with 
these* physical conditions and their relations to 
pulmonary affections the student is supposed to be 
familiar (vide page 20 et seq.). 

The signs of disease furnished by percussion are 
resolvable into six, namely : 1. Absence of resonance 
or flatness ; 2. Diminished resonance or dulness ; 
3. Tympanitic resonance ; 4. Vesiculo-tympanitic 
resonance ; 5. Amphoric resonance ; and 6. Cracked- 
metal resonance. The two last named signs are 
properly varieties of tympanitic resonance, but it is 
most convenient to consider them as distinct signs. 

Knowledge of these six signs sufficient for their 
availability in physical diagnosis requires, first, a 
practical acquaintance with the characters which 
distinguish each from the others, as well as from 
the normal resonance; and second, the significance 



ABSENCE OF KESONANCE OR FLATNESS. 59 

of each, that is, the morbid physical conditions 
which they severally represent. Under these two 
aspects the signs will now be considered. 

1= Absence of Resonance or Flatness. 

This sign is sufficiently defined by its name. It 
is absence of resonance or sound. Nothing is heard 
but a noise such as may be produced by percussing 
over a solid mass, for example a limb composed of 
muscle and bone, or over a collection of liquid, for 
example the abdomen in hydro-peritoneum or ascites. 
There being no resonance or sound, the sign has no 
characters pertaining to pitch or quality. It may 
be illustrated on the healthy chest by percussing in 
the right infra-mammary region below the line of 
hepatic flatness. 

There are four classes of morbid physical conditions 
giving rise to flatness on percussion, namely, 1st, a 
certain quantity of liquid in the pleural sac, in the 
substance of the lungs, or in pulmonary cavities; 
2d, liquid filling the air vesicles ; 3d, complete 
solidification of lung ; and 4th, a tumor within the 
chest. Flatness on percussion always represents one 
of these morbid physical conditions. 

These conditions are incident to different diseases, 
as follows : — 

1st. Liquid in the pleural cavity is incident to 
pleurisy with effusion, empyema, and hydrothorax. 
A collection of liquefied exudation within the lungs 
is incident to phthisis. A collection of pus consti- 
tutes pulmonary abscess, and phthisical cavities, or 
those caused by circumscribed gangrene, may become 
filled with morbid liquid products. 



60 PERCUSSION IX DISEASE. 

2d. Serous effusion into the air vesicles constitutes 
pulmonary oedema. Liquid hlood extravasated 
characterizes hemorrhagic infarctus, pneurnorrhagia 
or pulmonary apoplexy. Pus infiltrating more or 
less of the parenchjmia may he derived from an 
abscess either within the lung, or elsewhere, for ex- 
ample the liver, and from the pleural cavity in 
empyema, when perforation of lung takes place. 

3d. Solidification of lung occurs in pneumonia 
from an exudation within the air cells ; it is produced 
by condensation from compression by liquid or air 
in the pleural sac, the pressure of a tumor, and by 
collapse ; it exists in cases of phthisis, in interstitial 
pneumonia, and in carcinomatous infiltration of lung. 

4th. Tumors within the chest are of different kinds, 
for examples, aneurisms and cancerous growths. 
In proportion to their size they occupy space be- 
longing to the lung, as well as condensing the latter 
by pressure. Flatness may also be caused by the en- 
croachment of organs situated below the diaphragm 
upon the thoracic space, as in cases of enlargement 
of the liver and spleen. 

Flatness on percussion in all these conditions is 
the same. The sign alone does not enable us to 
discriminate the conditions from each other, or to 
determine the existing disease. 

Finding this sign present, the particular condition 
and the disease in each case are to be determined by 
the situation of the flatness, its extent, the associated 
physical signs furnished by auscultation, together 
with the other methods of exploration, and by the 
symptomatic events. 



DIMINISHED RESONANCE OR DULNESS. 61 

2. Diminished Resonance or Dulness. 

The resonance on percussion is diminished, or 
there is dulness, when the solids or liquids within 
the chest are morbidly increased without increase 
in the quantity of air, the increased amount of 
solids or liquids not being sufficient to cause flatness. 
Diminution of air, without increase of either solids 
or liquids, as in collapse of pulmonary lobules, also 
gives rise to dulness. We may formularize the 
physical conditions by saying that they consist in 
an abnormal proportion of solids or liquids over the 
air in the pulmonary vesicles. 

Dulness varies in degree. It may be slight, very 
slight, moderate, considerable, or great. These adjec- 
tives of quantity express sufficiently the variations 
in this regard. The degree of dulness corresponds 
to the amount of the relative disproportion of solids 
or liquids over the air within the chest. 

The pitch of sound is higher than that of the normal 
resonance of the persons percussed. This is invariable ; 
with dulness there is always more or less elevation 
of pitch. The quality is altered only in amount; 
there is, of course, less vesicular quality in propor- 
tion as the intensity of the resonance is diminished. 

The characters which distinguish this sign, thus, 
are, lessened intensity of resonance, elevation of 
pitch, and weakened vesicular quality. 

The morbid conditions giving rise to this sign are 
those which, existing in a greater degree, give rise 
to flatness. Morbid products within the pleural sac, 
serum, pus, lymph, if not sufficient to cause flatness, 
give rise to dulness. The sign, therefore, occurs in 
6 



62 PEKCUSSION IN DISEASE. 

pleurisy, empyema, and hydrothorax. The same is 
true of pulmonary oedema, hemorrhagic infarctus, 
pneumorrhagie and purulent infiltration of lung. 
Solidification of lung, when not complete, occasions 
dulness ; hence, it is a sign in pneumonia, vesicular 
and interstitial, in phthisis, in condensation of lung 
from compression, in collapse of pulmonary lobules, 
and in carcinomatous infiltration. A tumor within 
the chest, not sufficiently large to cause flatness, 
gives rise to dulness. 

There are, however, some conditions giving rise 
to dulness, which are never sufficient to cause flat- 
ness. Pulmonary congestion limited to a lobe may 
diminish the resonance appreciably. Thus dulness 
may exist in the first stage of pneumonia, before 
solidification from pneumonic exudation has taken 
place. A thin layer of lymph upon the pleural sur- 
faces causes dulness after the liquid effusion in 
pleurisy has been removed, and after the vesicular 
exudation in pneumonia is absorbed. Dulness may 
also be caused by a considerable accumulation of 
mucus or coagulated blood within the intra-pulmo- 
nary bronchial tubes. 

The particular morbid condition which gives rise 
to dulness cannot be inferred from the characters of 
the sign; the sign only denotes that some one of the 
different conditions exists. The condition which 
exists in each case, and the disease, are to be deter- 
mined by the situation, extent, and degree of dulness, 
taken in connection with the information derived 
from other methods of exploration than percussion, 
together with the history and symptoms. 



TYMPANITIC RESONANCE. 63 

3. Tympanitic Resonance. 

Resonance is tympanitic whenever it is entirely 
devoid of the vesicular quality ; in other words, any 
resonance which is non-vesicular is tympanitic. The 
leading distinctive character of the preceding sign 
(dulness) relates to intensity, whereas, the leading 
distinctive character of this sign relates to quality. 
Tympanitic resonance derives no distinctive char- 
acter from intensity ; it may be either more or less 
intense than the resonance of health in the person 
percussed. This point is to be impressed, inasmuch 
as with many the idea of a tympanitic resonance in- 
volves increased intensity of sound; a resonance, be it 
never so feeble, if it be non-vesicular, is tympanitic. 
If, however, the resonance be quite feeble, it is not 
always easy to determine whether there be or be not 
any appreciable vesicular quality. The term used 
by Stokes, namely, " tympanitic dulness," is properly 
enough applied to a resonance with diminished 
intensity, in which a vesicular quality cannot be 
appreciated. As regards pitch, a tympanitic reso- 
nance is higher than the normal vesicular resonance. 
If there be any exceptions to this rule, they are ex- 
tremely infrequent. The tympanitic resonance over 
different parts of the abdomen is always higher in 
pitch than the resonance over healthy lung. 

The following are the morbid physical conditions 
which give rise to tympanitic resonance: — 

1st. Air in the pleural cavity. It is, therefore, a 
sign of pneumothorax. Frequently, in this affec- 
tion, the tympanitic resonance- is more intense than 
the resonance of health, the pitch being more or less 
raised. 



64 PERCUSSION IN DISEASE. 

2d. Pulmonary cavities containing air. It occurs 
therefore in cases of phthisis.- In this disease the 
tympanitic resonance is limited to a circumscribed 
space corresponding to the site and size of the cavity, 
whereas, in pneumothorax, it frequently exists over 
a considerable part or the whole of the affected side 
of the chest. 

3c/. Complete solidification of the whole or a part 
of the upper lobe of a lung. The tympanitic reso- 
nance, under these circumstances, must be derived 
from the air in the lower part of the trachea and the 
bronchial tubes exterior to the lungs. This is the 
explanation of the sign in the second stage of pneu- 
monia affecting an upper lobe, and in certain cases 
of phthisis prior to the stage of excavation. Dilata- 
tion of the intra-pulmonary bronchial tubes, with 
solidification surrounding them, as in some cases of 
interstitial pneumonia or cirrhosis of lung, may give 
rise to tympanitic resonance. 

4th. Conduction of resonance from the stomach or 
colon containing air or gas. A gastric tympanitic 
resonance is frequently conducted over a part, and 
sometimes over the whole of the left side of the chest. 
This is more likely to occur when the left lung is 
solidified and rendered thereby a better conductor 
of sound. On the right side less frequently a tym- 
panitic resonance may he conducted upward from 
the colon to a greater or less extent. 

4. Vesiculo-Tympairitic Eesonance. 

This name was proposed by the author many 
years ago to denote a sign with the following dis- 
tinctive characters: The resonance increased in 



a:\iphoeic kesonance. 65 

intensity ; the quality, a combination of the vesicu- 
lar with the tympanitic, and the pitch high in 
proportion as the tympanitic quality predominates 
over the vesicular. 

This sign represents especially one morbid physical 
condition, namely, an abnormal accumulation of air 
in consequence of dilatation of the air vesicles, that 
is, pulmonary or vesicular emphysema, The sign 
also is present in interstitial or interlobular emphy- 
sema. The relation of the sign to these affections 
renders it of great value in physical diagnosis. 

A vesiculotympanitic resonance is obtained, when 
the pleural sac is partially filled with liquid, by 
percussing over the lung on the affected side. Al- 
though the pressure of the liquid diminishes the 
volume of the lung, as a rule it yields this sign. 
The resonance is vesiculotympanitic above the 
liquid when the latter is sufficient to fill a third, 
a half, or even two-thirds of the intra-thoracic space. 
The sign is also obtained over the upper lobe when 
the lower lobe is solidified in the second stage of 
pneumonia, and over the lower lobe when the upper 
lobe is solidified. 

5. Amphoric Resonance. 

Resonance is said to be amphoric when it has a 
musical intonation analogous to that produced by 
blowing over the mouth of an empty bottle. An 
amphoric sound is easily illustrated by filliping the 
cheek made tense, the mouth not completely closed 
and the jaws separated, as is done when the Sound of 
a liquid flowing from a bottle is imitated. By 
varying the size of the cavity of the mouth, the 

6* 



(56 PEKCUSSION IN DISEASE. 

amphoric sound thus produced may be made to vary 
much in pitch. This illustration exemplifies the 
mechanism of the sism in disease. 

The sign represents a pulmonary cavity which is 
generally phthisical. The conditions, aside from the 
existence of the cavity, are, rigidity of its walls, so 
that they do not collapse, the presence, of course, of 
air within the cavity, and free communication with 
the bronchial tubes. These accessory conditions are 
not constant, so that an amphoric resonance over a 
cavity is sometimes found, and at other times want- 
ing. Directly after having been wanting, it may be 
reproduced if the patient expectorate freely. 

When percussion is made with reference to this 
sign, the mouth of the patient should be open, and 
one or two rather forcible blows are better than a 
series of four or six. The amphoric sound may be 
often distinctly perceived if the ear be brought into 
close proximity to the patient's open mouth, when 
the sign is not appreciable otherwise. It may be 
rendered still more distinct by means of the binaural 
stethoscope, the pectoral extremity being close to 
the mouth of the patient. 

As a cavernous sign the amphoric resonance is 
very reliable ; but it does not invariably denote a 
pulmonary cavity. It is obtained in some cases of 
pneumothorax, the pleural space filled with air 
having a cavity which communicates with the 
bronchial tubes through a perforation of the lung 
situated above the level of the liquid. It is some- 
times obtained over a solidified portion of lung 
situated in close proximity to a primary bronchus, 
the resonance being derived from the air within the 



CRACKED-METAL RESONANCE. 67 

latter. It is occasionally produced by percussing 
over the site of the primary bronchus in the second 
stage of pneumonia affecting an upper lobe. In 
children, owing to the yielding of the costal car- 
tilages, it may even be produced in health over a 
primary bronchus. In all these exceptional in- 
stances, the associated signs and symptoms will 
prevent the error of attributing the sign to a pul- 
monary cavity. 

This sign is properly a variety of tympanitic reso- 
nance. 

6. Cracked-metal Resonance. 

The name of this sign, expressing an analogy to 
the sound produced by striking a cracked metallic 
vessel, denotes its peculiar character. It may be 
imitated by folding the hands so as to form a cavity 
and striking them upon the knee, in the familiar 
trick of producing in this way a sound as if metal 
coins were between the palms. This illustration, 
also, exemplifies the mechanism of the sign. Like 
the sign last described, the sign is a variety of tym- 
panitic resonance. 

The cracked-metal, like the amphoric, resonance 
represents generally a phthisical cavity. Percussion 
is to be made in the same way as for the production 
of the amphoric resonance, and, like the latter, the 
cracked-metal character is often perceived if the ear 
be brought close to the patient's mouth when other- 
wise it is not appreciable. 

The cracked-metal and the amphoric resonance 
are often associated; and the statements made with 
respect to the exceptional instances in which the 



68 PERCUSSION IN DISEASE. 

latter is produced, without the existence of a pul- 
monary cavity, will apply equally to the former. 

In addition to the acoustic phenomena produced 
by percussion, with the lingers applied to the chest 
instead of a pleximeter, the percussor can appre- 
ciate an abnormal sense of resistance in certain con- 
ditions of disease. In health, with a somewhat 
forcible percussion, the walls of the chest are felt 
to yield in proportion as the costal cartilages are 
flexible. This yielding is diminished or ceases when 
a collection of liquid in the pleural cavity, or liquid 
in the air vesicles, and solidification of lung, offer a 
mechanical obstacle thereto. An abnormal sense of 
resistance on percussion, thus determinable by com- 
parison of the two sides of the chest, is a sign repre- 
senting some one of the morbid physical conditions 
just named. This properly belongs among the signs 
obtained by palpation. The sign is to be taken in 
connection with other signs in determining the con- 
dition which exists in particular cases. 



CHAPTER IV. 

AUSCULTATION IN HEALTH. 

Importance of the study of the auscultatory sounds in health — Imme- 
diate and mediate auscultation — Advantages of the binaural stetho- 
scope — Rules to be observed in auscultation — Divisions of the study of 
auscultation in health — The normal laryngeal and tracheal respiration 
— The normal vesicular murmur ; its distinctive characters ; and the 
variations in the different regions on the same side, and in correspond- 
ing regions on the two sides of the chest — The normal vocal resonance 
— The laryngeal and tracheal'voice and whisper — The normal thoracic 
vocal resonance and fremitus ; the distinctive characters of each ; the 
variations in different regions on the same side, and in corresponding 
regions on the two sides of the chest — The normal bronchial whisper, 
with its variations in different regions on the same side, and in corre- 
sponding regions on the two sides of the chest. 

The term auscultation, limited in its application 
to the respiratory system, denotes the act of listen- 
ing to the normal and abnormal sounds produced by 
respiration, voice, and cough. In this and the next 
chapter, the method of exploration thus named will 
be considered in its application to the respiratory 
system ; it will be considered subsequently, as applied 
to sounds relating to the circulatoiy system. 

The study of auscultatory sounds in health is es- 
sential as preparatory for the study of auscultation 
in disease. The student must be familiar with the 
normal sounds before undertaking to become ac- 
quainted with those which represent morbid condi- 
tions. Ample time and attention should be given 
to the study of auscultation in health. The omis- 
sion to do this is a frequent cause of difficulty and 



TO AUSCULTATION IN HEALTH. 

want of success in attaining to a satisfactory pro- 
ficiency in physical diagnosis. The practical tact 
and skill required in diagnosis may be obtained in 
advance by devoting sufficient study to the healthy 
chest before entering on the study of the ausculta- 
tory signs of disease. Moreover, as will be seen, 
some of the most important morbid signs have their 
analogues in certain normal sounds pertaining to the 
respiratory system. 

Auscultation is either immediate or mediate. It 
is immediate when the ear is applied directly to the 
chest, which may be either denuded or covered with 
a cloth or more or less of the clothing. It is mediate 
when the sounds are conducted to the ear by means 
of an instrument called a stethoscope. The student 
should practise both immediate and mediate auscul- 
tation. The direct application of the ear to the chest 
suffices for diagnosis in many cases of disease ; but 
there are sometimes objections to this by the patient 
on the score of delicacy, and by the auscultator on 
the score of the uncleanliness of the person examined. 
There are certain parts of the chest which can only 
be explored by a stethoscope, and this instrument 
has the advantage of circumscribing the space 
whence the auscultatory sounds are derived. More- 
over, by means of the stethoscope which is to be 
preferred over the great variety of instruments here- 
tofore in use, the sounds are heard much better than 
by immediate auscultation. 

The stethoscope which is to be preferred conducts 
the sounds into both ears, that is, it is binaural. In 
this consists its great superiority. At the present 



AUSCULTATION IN HEALTH. 71 

time what is known as Cammann's stethoscope 1 
seems to combine more recommendations than any 
other form of a binaural instrument. The conduc- 
tion into both ears renders the sounds much louder 
and more distinct than when they are heard with 
one ear in either mediate or immediate auscultation. 
Another advantage is, the mind is not distracted by 
sounds entering the ear not employed in ausculta- 
tion. The advantages, however, of Cammann's 
stethoscope are not appreciated until after some 
practice. At first, a humming sound is heard 
which divides the attention and thus obscures the 
intra-tboracic sounds. After a little practice this 
bumming sound is not heeded, and it ceases to be 
any obstacle. Many who use the instrument only 
a few times are dissatisfied with it, and discontinue 
its use, when if they had used it longer they would 
not have been willing to dispense with it. The 
author's experience with a large number of classes 
in private instruction has been this : at first, most 
members of a class prefer the ear applied directly to 
the chest ; but, before the course of instruction is 
ended, the binaural stethoscope is so much preferred 
that it is difficult to enforce a fair proportion of 
practice in immediate auscultation. 

Another reason for the fact that this stethoscope 
is not sufficiently appreciated in this country is, 
many of the instruments sold are defectively made. 
Unless proper attention has been paid to all the nice 
points of the stethoscope as devised by Cammann, 
an instrument is worthless. An instrument must be 

1 Invented by the late Dr. Cammann, of New York. 



72 AUSCULTATION IX HEALTH. 

very good, or it is without any value. The knobs 
which are to enter the ears must be of the right 
size ; if they enter too far they occasion pain. The 
curves at the aural extremity must be such that the 
aperture is in the direction of the meatus of the ear. 
The flexible tubes must not be stiff, and their move- 
ments must be noiseless. All the tubes must be un- 
obstructed, for it is the air within the tubes which 
chiefly conducts the sounds. In the use of the in- 
strument it should be applied to the chest without 
any intervening clothing. 1 

The rules to be observed in the practice of aus- 
cultation, in health and disease, may be here intro- 
duced. 

Iu auscultation, as in percussion, corresponding 
situations on the two sides of the chest are to be 
explored successively, and compared. When the 
stethoscope is used, the pectoral extremity must be 
applied on each side with the same degree of pressure ; 
this is especially essential in the comparison of vocal 
sounds. In immediate auscultation, the ear is to 
be applied with a certain degree of force, and a 
thin layer of clothing does not interfere materially 
with the perception of auscultatory sounds. The 
ear not applied to the chest may or may not be 
closed by the finger in listening to the respiratory 
sounds; it should be closed in listening to the vocal 
sounds, in order to prevent confusion from attention 
to the voice from the patient's mouth. In immediate 
auscultation, whenever practised, the auscultator 
should take a position which will not interfere with 

1 The stethoscopes made by Tieinami & Co. are reliable. 



AUSCULTATION IN HEALTH. 73 

the sense of hearing, and not occasion a feeling of 
discomfort. These difficulties are in the way of 
auscultating with the body bent forward ; the sense 
of hearing is dulled, by the gravitation of blood to 
the head, and the position cannot be maintained 
without discomfort. The person examined, if prac- 
ticable, should be sitting, and the best position for 
the auscultator is that of kneeling on one knee, and 
lowering, if necessary, the body, so that the head 
may be kept upright. These points need not be 
observed if the binaural stethoscope be used. 

When listening to respiratory sounds, it is gene- 
rally desirable that the person examined should 
breathe with somewhat greater force than in ordinary 
breathing ; but it is important that the normal 
rhythm of respiration should be unchanged. Persons 
when requested to breathe with increased force are 
apt to err in breathing violently, and sometimes too 
slowly. The readiest mode of obtaining what is 
desired, is for the examiner to illustrate it by his 
own breathing. A complete expiration is impor- 
tant in order to secure a satisfactory inspiration. 
It should, therefore, be made clear, by explanation 
and illustration, that each expiration should be 
finished before the following inspiration. 

The ability to abstract the mind from thoughts 
and other sounds than those to which the attention 
is to be directed, is essential to success in auscul- 
tation. All persons do not possess equally this 
ability, and herein is an explanation in part of the 
fact that all are not alike successful. To develop 
and cultivate by practice the power of concentration, 
is an object which the student should keep in view. 
7 



74 AUSCULTATION IN HEALTH. 

Generally, at first, complete stillness in the room is 
indispensable for the study of auscultatory sounds; 
with practice, however, in concentrating the atten- 
tion, this becomes less and less essential. 

The study of auscultation in health embraces the 
following: — 

1. The sounds produced by respiration as heard 
over the larynx and trachea, or the normal laryngeal 
and tracheal respiration. 

2. The sounds heard over the chest in the acts of 
respiration. These sounds, coming chiefly from the 
air-vesicles, constitute what is called the normal 
vesicular murmur. 

3. The resonance, as heard over the chest, and the 
vibration or thrill produced by the loud voice, or the 
normal vocal resonance and fremitus. 

4. The sounds, as heard over the chest with the 
whispered voice, or, inasmuch as these sounds are 
conducted chiefly by the air in the bronchial tubes, 
the normal bronchial whisper. 

These four normal sigms will be considered in the 
foresfoino; order. 

Normal Laryngeal and Tracheal Respiration. 

For all practical purposes the laryngeal and the 
tracheal respiration may be considered to be identical, 
that is, the shades of difference between the sounds 
in these two situations are not of importance as 
regards the application to physical diagnosis. The 
laryngeal respiration is more readily studied than 
the tracheal, and, for the stud}' of both, the stetho- 
scope is necessary. 



NORMAL LARYNGEAL RESPIRATION. 75 

Applying the stethoscope over the side of the 
larynx, the person examined breathing with some 
increase of force, but without any alteration in 
rhythm, a sound is heard with each of the two acts 
of respiration. The inspiratory and the expiratory 
sound, studied separately and contrasted with each 
other, have the following characters relating to in- 
tensity, pitch, quality, duration, and rhythm: The 
inspiratory sound is of variable intensity. In ordi- 
nary breathing it varies much in different persons, 
and in different acts of breathing in the same person. 
It is always considerably intense in forced breathing. 
The pitch is high when compared with the inspira- 
tory sound as heard over the chest. The quality of 
the sound is well defined by the word tubular; the 
sound at once suo-o-ests a current of air through a 
tube. The duration of the sound is from the begin- 
ning to nearly, not quite, the end of the inspiratory 
act. The characters of the inspiratory sound, thus, 
are more or less intensity, a high pitch, a tubular 
quality, and a duration a little less than that of the 
act of inspiration. 

An expiratory sound is always heard with forced 
breathing. As regards duratiou, it is as long as, or 
longer than, the sound of inspiration. In general 
it is more intense than the sound of inspiration. The 
pitch is higher than that of the inspiratory sound. 
The quality is the same as that of the inspiratory 
sound, namely, tubular. 

Repeating the characters distinctive of the normal 
laryngeal respiration, they are as follows: The in- 
spiratory sound is of variable intensity, high in 
pitch, and tubular in quality. The expiratory sound 



76 AUSCULTATION IN HEALTH. 

is as long as, or longer than, the inspiratory sound ; 
it is higher in pitch, and usually more intense. 
Owing to the inspiratory sound not continuing quite 
to the end of the inspiratory act, there is a very short 
interval between the two sounds. In this latter point 
consists the only variation between the rhythm of 
the acts of breathing and that of the sounds. 

The foregoing characters should not only be veri- 
fied by the student, but he should become so familiar 
with them by practice that it requires no effort of 
the mind to recollect them. It will be seen here- 
after that these characters of the normal laryngeal 
respiration are precisely those which distinguish an 
important morbid physical sign, namely, the bron- 
chial or tubular respiration. 

Normal Vesicular Murmur, 

This is the name usuall} 7 given to the respiratory 
sounds heard over the different regions of the chest. 
These sounds should be studied with the ear applied 
directly to the chest (immediate auscultation), as 
well as with the stethoscope. In commencing the 
study, the middle of the anterior surface of the 
chest on the right side, to avoid the sounds of the 
heart, or, still better, the posterior aspect below the 
scapula on either side, should be selected. The 
person examined should breathe somewhat more 
forcibly than in ordinary breathing, but not vio- 
lently or quick!} 7 , nor too slowly, the normal rhythm 
being unchanged. Children are better than adults 
for this study, owing to the greater intensity of the 
murmur in early life. 



NORMAL VESICULAR MURMUR. (( 

The diameters which belong to the inspiratory 
and the expiratory sound in the normal vesicular 
murmur are as follows : The inspiratory sound is of 
variable intensity. There is a wide variation in 
different healthy persons. In some persons it is so 
feeble as scarcely to be appreciable even with the 
binaural stethoscope. The pitch of the sound, com- 
pared with the inspiratory sound in the normal 
laryngeal or tracheal respiration, is notably low. 
The quality of the sound is peculiar; no distinct 
idea of the quality can be formed by any comparison. 
The name used to designate the quality is vesicular, 
this name only denoting that the air vesicles are in 
some way concerned in the production of the sound. 
This vesicular quality must be impressed upon the 
perception and memory by direct observation, The 
duration of the inspiratory sound is from the begin- 
ning to the end of the inspiratory act. 

An expiratory sound is not always, although 
generally, appreciable. It is much less intense than 
the sound of inspiration. It is notably lower in 
pitch than the sound of inspiration. The quality 
of the sound is neither vesicular nor tubular. It 
may be called simply a blowing sound, and may 
be imitated by blowing with the mouth partially 
opened. The duration is much shorter than that of 
the inspiratory sound. 

The characters, thus, which distinguish the normal 
vesicular murmur are, an inspiratory sound variable 
in intensity, low in pitch, and vesicular in quality ; 
an expiratory sound less intense than the inspiratory, 
still lower in pitch, non-vesicular and non- tubular, 
or simply blowing ; the inspiratory sound continu- 

7* 



78 AUSCULTATION IN HEALTH. 

ing from the beginning to the end of the inspiratory 
act, and the expiratory sound beginning with the 
expiratory act but ending before this act is completed, 
its duration, relatively to the inspiratory sound, 
being variable, but averaging about a fifth. The 
inspiratory sound continuing to the end of inspira- 
tion, and the expiratory sound beginning with the 
act of expiration, it follows that there is no interval 
between the two sounds. It is to be remarked that 
an interval is not infrequently produced by the per- 
son examined holding the breath after inspiration is 
completed. This variation in the rhythm of the 
acts, of course, produces a corresponding variation 
in sounds of breathing. 

The student should verify these characters, com- 
pare them with the characters of the normal laryn- 
geal respiration, and become practically familiar with 
the differential points. He should then proceed to 
study the normal vesicular murmur in the different 
regions of the chest. The murmur will be found to 
present variations in the different regions on the 
same side, and in the corresponding regions on the 
two sides of the chest. The variations, within the 
range of health, in the latter are especially important. 
The following account of the murmur in the different 
regions embodies the results of a series of recorded 
examinations of healthy persons. 

Right and Left Infra-clavicular Region. — The 
murmur in this region, on either side, differs more 
or less from the murmur as heard in the anterior 
regions below, or in the infra-scapular region. The 
vesicular quality in the inspiration is less marked. 
The pitch is higher. The expiratory sound is longer, 



NORMAL VESICULAR MURMUR. 79 

less feeble, and higher in pitch. The difference 
between the two sides in this region is especially 
important with reference to diagnosis. The intensity 
of the inspiratory sound is almost invariably greater 
on the left side. Its vesicular quality is more marked, 
and the pitch is lower. Per contra, the inspiratory 
sound on the right side, in this region, is less intense, 
less vesicular, and higher in pitch than the inspira- 
tory sound on the leftside. In forced breathing the 
intensity of the murmur is increased more on the left 
than on the right side. The expiratory sound is 
sometimes wanting on the left, when it is heard on 
the right side. On the right side, the expiratory 
sound is longer than on the left side. It may be 
prolonged on the right side to nearly or quite the 
length of the inspiratory sound. Sometimes on the 
right side the pitch of the expiratory is higher than 
that of the inspiratory on the same side, and it may 
have a tubular quality. A rare peculiarity is a pro- 
longed, high, tubular expiratory sound on both sides, 
analogous to the laryngeal or tracheal expiration. 
When this is the case, the pitch of the expiratory 
sound is higher on the left than on the right side. 

These several modifications of the respiratory 
murmur in the infra-clavicular region are marked 
in proportion as the sounds are studied near the 
sternum, that is, over the site of the primary bronchi. 
The respiratory murmur in this situation has been 
called the normal bronchial respiration, from its 
resemblance to the morbid sign so named. It may 
be more properly called a vesiculo-tubular, or the 
normal broncho-vesicular respiration, the characters 



80 AUSCULTATION IN HEALTH. 

being those of the morbid sign which, under the 
latter name, will be described in the next chapter. 

In the diagnosis of diseases, especially of phthisis, 
due allowance must be made for the points of dis- 
parity which exist normally between the two sides 
of the chest in the infra-clavicular region. Without 
a practical knowledge of these points of disparity, 
error in diagnosis can hardly be avoided. 

Right and Left Scapular Region. — As compared 
with the infra-clavicular region, the respiratory 
murmur heard over the scapula on either side is 
feeble, and the vesicular quality is less marked. 
The inspiratory sound is generally weaker and the 
pitch higher on the right than on the left side. 
The expiratory sound is more constantly heard on 
the right than on the left side. It may be prolonged 
on the right side, and is sometimes higher in pitch 
than the inspiratory sound. Compared with the 
left side, the murmur on the right, in this region, 
thus may have vesiculo-tubular or broncho-vesicu- 
lar characters more or less marked. 

Right and Left Interscapular Region. — In the 
upper and middle portions of this region, the normal 
characters are the same as in the sterno-clavicular 
portion of infra-clavicular region. The same points 
of disparity between the two sides are more or less 
marked here as they are anteriorly over the site of 
the primary bronchi. 

Right and Left Infra-scapular Region. — The inten- 
sity of the murmur is greater than over the scapular 
region. In most persons there is no notable dis- 
parity between the two sides ; when a disparity 
exists, the intensity is greater and the pitch lower 



NORMAL VOCAL RESONANCE. 81 

on the left side. A prolonged, high pitched, bron- 
chial expiratory sound is sometimes transmitted 
below the scapula on the right side. 

Right and Left 31am mary and Infra-mammary 
Regions. — The inspiratory sound in these regions is 
less intense than in the infra-clavicular region; the 
vesicular quality is more marked, and the pitch is 
lower. An expiratory sound is often wanting. 

Right and Left Axillary and Infra-axillary Re- 
gions. — The inspiratory sound in these regions is as 
intense as in any portion of the chest. The inten- 
sity is less in the infra-axillary than in the axillary 
region, and the pitch is lower. In some persons the 
murmur on the two sides presents no disparity, but 
in other persons the vesicular quality is somewhat 
more marked and the pitch is lower on the left than 
on the right side. An expiratory sound is oftener 
heard than in the mammary and infra-mammary 
regions. 

Normal Vocal Resonance. 

Laryngeal and Tracheal Voice. — It will prepare 
the student for the appreciation of the distinctive 
characters of the morbid signs pertaining to the voice, 
to study the vocal signs over the larynx and trachea. 
Applying the stethoscope either over the broad sur- 
face of the thyroid cartilage, or just above the 
sternal notch, and requesting the person examined 
to count with a moderate intensity of voice, the 
auscultator perceives a strong resonance with a sen- 
sation of concussion or shock, and a sense of vibra- 
tion, thrill, or fremitus. The voice seems to be con- 
centrated and near the ear. Sometimes the articu- 



82 AUSCULTATION IN HEALTH. 

latecl words are transmitted so as to he heard more or 
less distinctly. Th e 1 a ry n gea 1 or t rach eal voice, t h u s 
(laryngophony, tracheophony), embraces different 
elements, namely, 1st, the vocal resonance ; 2d, the 
concentration and nearness to the ear ; 3d, the vibra- 
tion, thrill, or fremitus ; and 4th, the transmission 
of the speech, the latter corresponding to pecto- 
riloquy. These different elements will be found 
to enter into the distinctive characters of morbid 
vocal signs. 

The sounds heard over the larynx and trachea 
when words are spoken in a whisper should be 
studied, inasmuch as important morbid signs relate 
to the whispered voice. "Whispered words occasion 
little or no shock or thrill, but an intense, high 
pitched, tubular sound, with a sensation as if a 
current of air were directed into the ear through 
the stethoscope. This sound corresponds to the 
sound of expiration in laryngeal or tracheal respi- 
ration ; the two sounds are, in fact, identical if, as 
is the case with some exceptions, the person whisper 
with the expiratory breath. Articulated words are 
transmitted with more or less distinctness, corre- 
sponding with the morbid sign called whispering 
pectoriloquy. 

Normal Thoracic Vocal Resonance and Fremitus. — 
The vocal resonance over the chest is to be studied 
both by means of the stethoscope and by immediate 
auscultation. When the latter is employed, the ear 
not applied to the chest should be closed, in order to 
exclude the entrance of sound from the mouth of 
the person examined. When the stethoscope is em- 
ployed, care must betaken, in making a comparison 



NORMAL VOCAL RESONANCE. 83 

between the two sides of the chest, or between dif- 
ferent regions on the same side, that the pectoral 
extremity of the instrument be pressed with an equal 
amount of force against the chest. The intensity 
with which the vocal resonance is transmitted, is 
much affected by the degree of pressure with the 
stethoscope. 

The situations in which the student should com- 
mence the study of the normal vocal resonance are 
those selected for beginning the study of the normal 
vesicular murmur, namely, the middle of the ante- 
rior aspect of the chest on the right side, and below 
the scapula behind. 

With the stethoscope or the ear directly applied 
in the situations just named, the person examined 
should be requested to count one, two, three, in a 
uniform tone, and with moderate force. The ex- 
aminer should himself pronounce these numerals, in 
order to show the manner of counting. This is far 
better than asking a question and studying the reso- 
nance during the answer of the person examined. 
The objection to the latter mode is, the attention of 
the examiner is divided between the characters of 
the thoracic resonance and the idea conveyed by the 
answer. The characters of the vocal resonance in 
these situations are as follows: — 

The voice is heard with an intensity which varies 
very much in different persons; in some the reso- 
nance is feeble, and it may be almost inappreciable, 
while in others it is quite intense. The intensity 
depends greatly on the loudness and lownessin pitch 
of the voice of the person examined. The resonance 
is notably weaker in women than in men. It is 



84 AUSCULTATION IN HEALTH. 

rarely attended with a sense of concussion or shock. 
It is diffused; that is, it does not seem to be concen- 
trated, like the tracheal or laryngeal vocal resonance. 
It evidently comes from a certain distance; that is, 
the sound does not seem to he near the ear. This 
latter character is distinctly appreciable, and is 
highly distinctive of the normal resonance as com- 
pared with a morbid vocal sign (bronchophony). 
The resonance is accompanied by a sense of vibra- 
tion, thrill, or fremitus, the intensity of which, like 
the resonance, varies much in different persons. 
This fremitus is properly not an acoustic but a tac- 
tile sign. The normal vocal fremitus, together with 
its abnormal modifications, belongs to the method 
of physical exploration called palpation. It is, how- 
ever, appreciated by the ear as well as by the touch, 
and may be studied in the practice of auscultation. 
The student should practically distinguish from each 
other, and study separately, the vocal resonance and 
vocal fremitus. 

From the foregoing characters the normal vocal 
resonance may be denned as, diffused, distant, vari- 
able in intensity, and accompanied with more or less 
vibration, thrill, or fremitus. 

Having become practically familiar with these 
characters of the normal vocal resonance in the 
situations in which they are first to be studied, the 
next object of study relates to the normal variations 
in the different regions on the same side of the chest, 
and in corresponding regions on the two sides. In 
giving an account of these variations, based on a 
series of recorded examinations in healthy persons, 
the different regions will be considered in the same 



NORMAL VOCAL RESONANCE. 85 

order as in the study of the variations of the respi- 
ratory sounds (vide p. 78 et seq.). 

Infra-clavicular Region. — The vocal resonance in 
this region on either side is more intense than in the 
anterior regions below, the intensity, however, in 
different persons being very variable; irrespective 
of intensity, it is less diffused, nearer the ear, and 
the pitch is somewhat higher. These latter varia- 
tions are marked chiefly in the sternoclavicular 
extremity of the region, that is, over the site of 
the primary bronchi. In some persons the concen- 
tration, nearness to the ear and elevation of pitch, 
especially on the right side, are such as to approxi- 
mate the normal resonance to the morbid sign called 
bronchophony. The characters of this sign will be 
considered in the next chapter; but it is important 
to know that exceptionally these characters may be, 
in a measure, illustrated in health in the infra-clavi- 
cular region. The resonance might then be termed 
normal bronchophony. 

A comparison of the resonance in the region on 
the right and on the left side always shows a dis- 
parity. The resonance on the right side is invariably 
greater. The degree of difference between the two 
sides varies in different persons. The resonance may 
be more or less marked on the right and nearly want- 
ing on the left side. Allowance is to be made for 
the points of normal disparity between the two sides 
in the diagnosis of disease; hence the student must 
become practically familiar with them. 

The vocal vibration or fremitus varies fully as 
much as the vocal resonance in different persons. 
Its intensity is not always proportionate to that of 



86 AUSCULTATION IN HEALTH. 

the resonance; that is, the resonance may be com- 
paratively weak when the fremitus is strong, and 
vice versa. The fremitus, like the resonance, is always 
greater on the right than on the left side, the dispa- 
rity, like that of the resonance, varying considerably 
in different persons. 

Scapular Region. — The resonance in this region is 
notably less intense than in the infra-clavicular re- 
gion. It is also more diffused and distant. The 
intensity is always greater on the right side. These 
statements are alike applicable to the vocal fremitus. 

Inter- scapular Region. — The intensity of the reso- 
nance here is nearly or quite as great as in the sterno- 
clavicular extremity of the infra-clavicular region. 
The resonance has in some persons in this region 
the characters of bronchophony. The intensity is 
always greater on the right side. The fremitus is 
more or less marked, and always more marked on 
the right than on the left side. 

Infra-scapular Region. — As a rule the resonance in 
this region is stronger than over the scapula. It is 
always characterized by diffusion and distance. As 
in all the regions it varies much in different persons, 
and is stronger on the right than on the left side. 
These statements are also applicable to fremitus. 

Mammary and Infra-mammary Regions. — The re- 
sonance is notably less than at the summit of the 
chest. The characters of bronchophony are never 
present. The intensity is greater on the right side. 
The same is true of fremitus. 

Axillary and Infra- axillary Regions. — The reso- 
nance in these regions, and especially in the axillary 
region, is greater than over the mammary and infra- 



NORMAL BRONCHIAL WHISPER. 87 

mammary regions. It is, of course, stronger on the 
right side. The characters, as contrasted with those 
of bronchophony, namely, distance and diffusion, are 
marked. Fremitus is more or less marked, and, of 
course, more marked on the right than on the left 
side. 

Normal Bronchial Whisper. 

Prior to the publication of the author's work on 
the "Physical Exploration of the Chest" in 1856, 
signs in health and disease relating to the whispered 
voice had received but little attention. In that 
work, and more fully in the second edition, pub- 
lished in 1866, a series of signs accompanying whis- 
pered words were described and named. As a point 
of departure for the study of the morbid signs thus 
obtained, of course, the signs in health must first be 
studied. The sounds which are heard over different 
parts of the chest in health I have embraced under 
the name, the normal bronchial whisper. The per- 
tinency of this name is derived from the fact that 
the conduction of the sound produced by the whis- 
pered voice must be chiefly by the air contained in 
the bronchial tubes. The sound heard over the 
trachea and larynx may be distinguished as the 
laryngeal or tracheal whisper, the characters of 
which have been already stated (vide page 82). 

It will facilitate the study of the normal bronchial 
whisper, as well as of the morbid signs, to consider 
that the characters of the sounds produced with the 
whispered voice, are identical with those produced 
by the act of expiration, in all respects, save inten- 
sity. Whispered words are produced, as a rule, by 



88 AUSCULTATION IN HEALTH. 

an act of expiration, the sounds being more intense 
generally than those which accompany even forced 
breathing. Curiously enough, there are exceptions 
to this rule. Some persons insist upon whispering 
with the act of inspiration, and there are some per- 
sons who have never acquired the ability to whisper. 
It will he at once evident that the pitch and quality 
of sounds produced by whispered words with the 
act of expiration, must be the same as those of the 
sounds of expiration in breathing. 

Selecting for beginning the study of the normal 
bronchial whisper the same situations as in com- 
mencing the study of the normal respiratory mur- 
mur, and the normal vocal resonance, namely, the 
middle of the chest in front, on the right side, 
and the infra- scapular region behind, with the whis- 
pered voice in these situations is heard, in most 
persons, a feeble, low-pitched, blowing sound, these 
characters corresponding to those of the expiratory 
sound in forced breathing. The normal bronchial 
whisper in these situations is not in all persons ap- 
preciable. 

In the infra-clavicular region, the bronchial 
whisper is heard, with variable intensity, in most 
persons. It is somewhat higher in pitch than the 
whisper below this region. It is louder and higher 
in the sterno-clavicular than in the acromial ex- 
tremity. In the former situation it has not infre- 
quently a tubular quality. It is louder on the right 
than on the left side of the chest. It is sometimes 
heard on the right when it is inappreciable on the 
left side. When heard on both sides the pitch of the 
sound is higher on the left than on the right side. 



NORMAL BRONCHIAL WHISPER. 89 

Lt will be observed that these variations correspond 
to those of the sound with expiration in the infra- 
clavicular region (vide page 79). Occasionally whis- 
pered words are partly transmitted, constituting in- 
complete whispering pectoriloquy. 

In the scapular region the bronchial whisper is 
not infrequently wanting. It may be present on 
the right and not on the left side, and, if present on 
both sides, it is always louder on the right side. 

In the inter-scapular region, as a rule, it is nearly 
or quite as marked as over the site of the primary 
bronchi in front. The pitch is more or less high, 
and lias a tubular quality. It is louder on the right 
and higher in pitch on the left side, and in this 
situation there may be incomplete pectoriloquy. 

In the infra-scapular region, it is not infrequently 
wanting. "When present, it is generally feeble, the 
pitch being low and the quality non-tubular or blow- 
ing. It is oftener wanting; on the left than on the 
right side, and, if present on both sides, it is louder 
on the right side. 

In the mammary and infra-mammary regions it is 
not infrequently wanting, and the statements just 
made with reference to the infra-scapular region are 
alike applicable to these, as also, to the axillary and 
infra-axillary regions. 



8* 



CHAPTER V. 

AUSCULTATION IN DISEASE. 

The respiratory signs of disease : — Abnormal modifications of the normal 
respiratory sounds : — Increased, vesicular murmur — Diminished vesicu- 
lar murmur — Suppressed respiratory sound — Bronchial or tubular 
respiration — Broncho-vesicular respiration — Cavernous respiration — 
Broncho-cavernous respiration — Amphoric respiration — Shortened in- 
spiration — Prolonged expiration — Interrupted respiration. Adventi- 
tious respiratory sounds or rales : — Laryngeal and tracheal rales — 
Moist bronchial rales, coarse, fine, and subcrepitant — Vesicular or 
crepitant rale — Cavernous or gurgling rale — Pleural friction rales, me- 
tallic tinkling and splashing. Indeterminate rales — The vocal signs 
of disease : — Bronchophony — Whispering bronchophony — iF-gophony 
— Increased vocal resonance — Increased bronchial whisper — Cavernous 
"whisper — Pectoriloquy — Amphoric voice or echo — Diminished and sup- 
pressed vocal resonance — Diminished and suppressed vocal fremitis — 
Metallic tinkling. Signs obtained by acts of coughing or tussive signs. 

The importance of becoming perfectly familiar 
with the signs of health before entering upon the 
study of morbid signs, cannot be too strongly en- 
forced. The auscultatory signs of disease, which are 
to be considered in this chapter, should not be 
studied until the student has made himself complete 
master of all the characters belonging to the normal 
signs obtained by auscultation. 

Auscultation in disease embraces the signs pro- 
duced by respiration, by the voice, and by acts of 
coughing. The respiratory signs will be first con- 
sidered. 

The Respiratory Signs of Disease. 
The signs produced by respiration may be classi- 
fied as follows: 1st. Those which are abnormal 



MODIFICATIONS OF NORMAL SOUNDS. 91 

modifications of the normal respiratory sounds. 2d. 
Those which have no analogues in health, being 
entirely new or adventitious sounds. The latter are 
embraced under the name rales. 

Abnormal Modifications of the Normal Respiratory Sounds. 

In order to appreciate the distinctive characters of 
the signs embraced in this class, the characters which 
distinguish the normal vesicular murmur must be 
kept in mind. The abnormal modifications which 
characterize these morbid signs relate to intensity, 
pitch, and quality of sound, together with certain 
alterations in rhythm. Eleven distinct modifications 
or signs are included under this heading, namely : 
1. Increased vesicular murmur ; 2. Diminished 
vesicular murmur ; 3. Suppression of respiratory 
sound ; 4. Bronchial or tubular respiration ; 5. 
Broncho-vesicular respiration ; 6. Cavernous respi- 
ration ; 7. Broncho-cavernous respiration ; 8. Am- 
phoric respiration ; 9. Shortened inspiration ; 10. 
Prolonged expiration ; and, 11. Interrupted inspi- 
ration or expiration. 

These signs are to be studied, first, with reference 
to their distinctive characters severally, each being 
contrasted, as respects these characters, with the 
other morbid respiratory signs as well as with the 
normal vesicular murmur; and, second, with refer- 
ence to the morbid physical conditions which they 
represent, that is, the diagnostic significance which 
belongs to each. 

Increased Vesicular Murmur. — This sio-n has but 
a single distinctive character, namely, increase of 
intensity. The murmur is abnormally loud, the 



92 AUSCULTATION IN DISEASE. 

characters of the normal vesicular murmur being in 
other respects not materially changed, that is, the 
pitch is low and. the quality vesicular as in health. 
Now, it has been seen {vide page 77) that the inten- 
sity of the healthy murmur varies much in different 
persons ; there is no ideal standard of normal inten- 
sity by reference to which an abnormal increase is 
to be determined. Yet, the increase under certain 
conditions of disease is such that the fact is suffi- 
ciently evident. It occurs on the healthy side of 
the chest when the respiratory function on the other 
side is annulled or much compromised by disease. 
This takes place in cases of pleurisy with large effu- 
sion, pneumonia, especially if more than one lobe be 
affected, obstruction of one of the primary bronchi, 
and pneumothorax. The sign does not possess 
great diagnostic importance, inasmuch as the nature 
and extent of the disease are determined by the 
signs obtained on the affected side. 

The sign has been called supplementary and puerile 
respiration. 

If the murmur be much intensified, it may possibly 
be mistaken for other morbid signs, namely, bronchial 
or broncho-vesicular respiration. This error, how- 
ever, can never be made if the distinctive characters 
of these signs relating to pitch and quality have 
been correctly studied. 

Diminished Vesicular Murmur. — The intensity of 
the vesicular -murmur may be on the one hand di- 
minished, when it is evident that in other respects 
there is no material change, and the murmur, on the 
other hand, may become so feeble that characters 
aside from the intensity are not determinable. From 



MODIFICATIONS OF NORMAL SOUNDS. 93 

the latter fact it follows that the murmur must 
sometimes be considered as only weakened, when, 
were the diminished intensity not as great, morbid 
changes in pitch and quality might be appreciable. 

The murmur is more or less weakened in cases of 
dilatation of the air cells, or vesicular emphysema, 
the sign, in these cases, being often accompanied by 
changes in rhythm, namely, a shortened inspiration 
and a prolonged expiration. Simple weakness of 
the murmur maj T also be incident to partial blocking 
of the air vesicles with blood or serum in cases of 
pulmonary extravasation and oedema. A deficient 
expansion of the chest, either on one side or on both 
sides, occasions weakness of the respiratory murmur. 
Deficient expansion of one side, or of both sides, may 
be caused by paralysis, bi-lateral, or unilateral, of 
the costal muscles. A similar effect is caused by 
paralysis of the diaphragm. The incomplete descent 
of the diaphragm from pain, as in peritonitis, or 
from mechanical obstacles as in peritoneal dropsy, 
pregnancy, and abdominal tumors, weakens the res- 
piratory murmur, the increased action of the costal 
muscles not being fully compensatory. Unilateral 
deficiency of expansion of the chest is caused by pain 
in intercostal neuralgia, pleurodynia, acute pleurisy, 
and pneumonia; it is also caused by the presence of 
a stratum of liquid, air, or a thick layer of lymph 
between the lung and the chest- wall in pleurisy, 
hydrothorax and pneumothorax. Swelling of the 
bronchial mucous membrane in bronchitis affecting 
the larger tubes, must diminish somewhat the in- 
tensity of the murmur. In primary bronchitis, the 
murmur is diminished on both sides. In bronchitis 



94 AUSCULTATION IN DISEASE. 

affecting the smaller tubes, the murmur is greatly 
diminished, if not suppressed, on both sides. In- 
complete obstruction of bronchial tubes from the 
presence of mucus, serum, blood, or pus, has this 
effect over an area corresponding to the size of the 
tubes obstructed. Spasm of the bronchial muscular 
fibres in paroxysms of asthma, diminishes, if it does 
not suppress, murmur on both sides. Another cause 
of diminution, unilateral, or within a limited space 
on one side, is the pressure of a tumor on bronchial 
tubes, as in cases of aneurism. A permanent con- 
traction or stricture of bronchial tubes is another 
cause. E"ot infrequently the pressure of an aneu- 
risnial tumor or an enlarged bronchial gland on a 
primary bronchus, occasions notable weakness of the 
murmur over the whole of one side ; and the pres- 
sure of a tumor on the trachea weakens the murmur, 
more or less, on both sides. A foreign body in one of 
the primary bronchi weakens it on one side. Dimi- 
nution of the calibre of the trachea or larynx from 
morbid growths, the presence of foreign bodies, 
fibrinous exudation, accumulations of mucus, sub- 
mucous infiltration, spasm of the laryngeal muscles, 
and swelling of the mucous membrane, weakens, in 
proportion to the amount of obstruction, the mur- 
mur on both sides without any material change in 
its quality and pitch. 

Weakened murmur at the summit of the chest, 
without other appreciable abnormal characters, oc- 
curs in some cases of phthisis, due to obstructed 
bronchial tubes from coexisting circumscribed bron- 
chitis, or to deficient superior costal movements of 



MODIFICATIONS OF NOEIAL SOUNDS. 95 

the chest, as well as to the presence of exudation in 
air vesicles. 

Diminished intensity of the vesicular murmur is 
thus seen to be a respiratory sign entering into the 
diagnosis of a considerable number of diseases, 
namely, emphysema, paralysis affecting the respira- 
tory muscles, asthma, abdominal affections interfer- 
ing with the diaphragmatic movements, intercostal 
neuralgia, pleurodynia, pneumothorax, acute pleu- 
risy, pneumonia, hydrothorax, bronchitis, asthma, 
aneurismal and other tumours, permanent constric- 
tion or stricture of bronchial tubes, laryngitis, oedema 
of the glottis, spasm of the glottis, the various lesions 
which occasion obstruction of the larynx or trachea, 
and phthisis. 

In determining a slight abnormal weakness of the 
respiratory murmur at the summit of the chest on 
the right side, the normal disparity between the 
two sides in this situation is to be borne in mind. 
The vesicular murmur is normally less intense on 
the right than on the left side. 

This sign occurring in so many diseases, it is ob- 
vious that, taken alone, that is, independently of 
other signs, it has not any special diagnostic signifi- 
cance. It is, however, often of value in diagnosis, 
when taken in connection with other signs. It is 
chiefly useful when it exists either over the whole 
or in a part of the chest on one side. 

Suppressed Respiratory Sound. — This sign is easily 
defined, namely, absence of all respiratory sound, as 
the name signifies. It cannot, of course, have any 
characters relating to intensity, pitch, and quality. 

Suppression of respiratory sound represents the 



96 AUSCULTATION IN DISEASE. 

same physical conditions as diminished vesicular 
murmur; the physical conditions represented hy the 
latter sign, existing in a greater degree, occasion ab- 
sence of all sound. It suffices, therefore, to recapitu- 
late the various conditions and diseases in connection 
with which the murmur may either he diminished 
or suppressed. Suppression over portions of the 
chest may be due to dilatation of the air-cells in 
cases of empyema. It occurs from the exclusion of 
air from the vesicles by the presence of "blood and 
serum in cases of pulmonary extravasation and 
oedema. Respiratory sound is sometimes wanting 
over lung solidified in cases of pneumonia and 
phthisis. Paralysis of the muscles concerned in 
respiration may possibly involve feebleness of the 
respiratory acts sufficiently to render the murmur 
inappreciable. In intercostal neuralgia, pleurodynia, 
acute pleurisy, and pneumonia, the movements of 
the affected side may be so much restricted as to 
abolish the murmur. In pleurisy with much effu- 
sion, empyema, hydrothorax, pneumothorax, the 
murmur is suppressed over either a part or the whole 
of the affected side, the extent of the suppression 
corresponding to the quantity of serum, pus, or air 
within the pleural cavity. Swelling of the mucous 
membrane in cases of bronchitis affecting the larger 
bronchial tubes is never sufficient to suppress the 
murmur, but plugging of more or less of the tubes 
with mucus or other morbid products may have this 
effect. In cases of bronchitis, the murmur is some- 
times found to have disappeared over a certain area, 
and to return after an act of expectoration. In 
bronchitis affecting the smaller tubes, suppression of 



MODIFICATIONS OF NORMAL SOUNDS. 97 

the murmur is not infrequent. It occurs from spasm 
of the bronchial muscular fibres in cases of asthma. 
The pressure of a tumour, morbid growths, or de- 
posits upon bronchi within the lungs, may abolish 
respiratory sound over a portion of the chest, and 
permanent stricture or obliteration of bronchial 
tubes have this effect. Respiratory sound may be 
suppressed over the whole of one side from the 
pressure of an aneurismal or some other tumour 
upon one of the primary bronchi. If the tumour 
press upon the trachea, the obstruction may be suffi- 
cient to suppress the murmur on both sides. A 
foreign body lodged in a primary bronchus may sup- 
press the murmur on one side, and, lodged in the 
larynx or trachea, the murmur may be suppressed on 
both sides. The different affections of the larynx 
and trachea which, in proportion to the amount of 
obstruction, weaken the murmur, may render it in- 
appreciable. 

Bronchial or Tabular Respiration. — The analogue 
of this sign is the normal laryngeal or tracheal respi- 
ration {vide page 74). The characters which distin- 
guish the latter normal sign from the normal vesicu- 
lar murmur, are those which are distinctive of the 
bronchial or tubular respiration. These characters, 
relating to the inspiratory and the expiratory sound, 
are as follows : The inspiratory sound is of variable 
intensity. Intensity does not enter into the distinc- 
tive characters of this sign ; the sound may be either 
louder or weaker than the inspiratory sound in 
health. The pitch of the inspiratory sound is high. 
The quality is expressed by the term tubular; it is 
like the sound produced by blowing through a tube, 
9 



98 AUSCULTATION IX DISEASE. 

this quality taking the place of that expressed by 
the term vesicular in the normal respiration. The 
expiratory sound is prolonged; it is as long as, or 
longer than, the sound of expiration, and is usually 
louder. The pitch is still higher than that of the 
inspiratory sound. The quality, like that of the in- 
spiratory sound, is tubular, this quality taking the 
place of the simple blowing quality of the expira- 
tory sound in the normal vesicular murmur." With 
the normal rhythm of the respiratory acts, there is 
a very brief interval between the souuds of inspira- 
tion and expiration, due to the fact that the inspira- 
tory sound ends a little before the end of the inspi- 
ratory act. 

The morbid physical condition represented by this 
important sign is either complete or considerable 
solidification of lung. Whenever the chest is aus- 
cultated over lung solidified, if there be not absence 
of respiratory sound, the sound is tubular. This 
significance renders the sign of diagnostic value in 
the diseases which involve solidification. The sign 
per se denotes simply this morbid physical condi- 
tion; the particular disease which exists is ascer- 
tained by means of the associated signs and the 
symptoms. 

Solidification of lung is incident to several differ- 
ent diseases. In lobar or vesicular pneumonia, it 
is due to a fibrinous exudation within the air vesi- 
cles. In phthisis it is caused by an exudation in 
the same situation. In chronic or fibroid pneu- 
monia the lung is solidified by an interstitial 
growth. The compression of lung from either pleu- 
ritic effusion, an accumulation of air in the pleural 



MODIFICATIONS OF NORMAL SOUNDS. 99 

cavity, or the pressure of a tumor, causes solidifi- 
cation by condensation. Collapse of pulmonary 
lobules also solidities by condensation. Coagula- 
tion of blood within the air vesicles (hemorrhagic 
infarctus), and cancerous infiltration or growth, are 
other causes of solidification. In these different 
affections, if the solidification be complete or con- 
siderable, this sign is usually present ; it is always 
present if there be not suppression of respiratory 
sound. 

It is sometimes the case that either the inspira- 
tory or the expiratory sound is wanting. The 
characters of the sign suffice for its recognition if 
either the inspiratory or the expiratory sound be 
alone present ; the pitch and the quality are distinc- 
tive. Both sounds are often so intense that they 
are diffused more or less without the limits of 
the solidified portion of lung. The expiratory 
sound, being more intense than the inspiratory, is 
transmitted further than the latter. This explains 
the conjunction sometimes of a vesicular inspiration 
with a tubular expiration; and a cavernous inspira- 
tion ma} 7 be conjoined with a tubular expiration, 
showing the proximity of solidified lung in the 
former case to healthy lung, and, in the latter case, 
to a pulmonary cavity. 

The sound may seem near the ear or to come from 
a certain distance. The latter is appreciable in some 
cases of large pleuritic effusion ; the tubular respira- 
tion is more or less distant, and it is sometimes diffused 
over the whole of the side which is filled with liquid. 

Broncho-vesicular Respiration. — This name was 
introduced by me in 1856 to denote the combination, 



100 AUSCULTATION IN DISEASE. 

in varying proportions, of the characters of the 
bronchial or tubular, and of the normal vesicular 
respiration. The name expresses such a combination. 

The sign represents the different degrees of solidi- 
fication of lung, between an amount so slight as to 
occasion only the smallest appreciable modification of 
the respiratory sound, and an amount so great as to 
approximate closely to the degree giving rise to 
bronchial or tubular respiration. In other words, 
all the gradations of respiratory modifications, caused 
by incomplete or an inconsiderable solidification, 
which fall short of bronchial or tubular respiration, 
are embraced under the name broncho-vesicular. 
The gradations correspond to the amount of solidi- 
fication, that is, they show the solidification to be 
either very slight, slight, moderate, or nearly suffi- 
cient to be considered as considerable or complete. 
The sign is therefore important as evidence, first, of 
the existence of solidification, and second, of the 
degree of solidification. 

Analyzing this sign, the most distinctive feature 
is the combination of the vesicular and the tubular 
quality in the inspiratory sound. These two quali- 
ties may be combined in variable proportions. The 
pitch of the sound is raised in proportion as the 
tubular predominates over the vesicular quality. 
The expiratory sound is more or less prolonged, 
tubular in quality, and the pitch is raised. The 
prolongation of this sound, its tubular quality, and 
the highness of pitch, are proportionate to the pre- 
dominance of the tubular over the vesicular quality 
in the inspiratory sound. If the solidification of 
lung be slight, the characters of the normal vesicular 



MODIFICATIONS OF NOEMAL SOUNDS. 101 

respiration predominate; that is, the inspiratory 
sound has but a small proportion of the tubular 
quality, and is but little raised in pitch, the expira- 
tory sound being not much prolonged, its tubularity 
not marked, the pitch not high. If, on the other 
hand, the solidification of lung be almost enough to 
give a bronchial respiration, the inspiratory sound 
has only a little vesicular quality, the tubular quality 
predominating, the pitch proportionately raised; 
and the expiratory sound is prolonged, tubular, and 
hiffh, nearly to the same extent as in the bronchial 
respiration. The less the solidification the more the 
characters of the normal vesicular predominate over 
those of the bronchial respiration, and, per contra, 
the greater the solidification the more the characters 
of the bronchial predominate over those of the nor- 
mal vesicular respiration. Daily auscultation in a 
case of lobar pneumonia during the stage of resolu- 
tion affords an opportunity to study all the grada- 
tions of this sign. After resolution has made some 
progress, the inspiratory sound is no longer purely 
tubular, but the ear appreciates a little admixture 
of the vesicular quality and the pitch is slightly low- 
ered. As the resolution goes on, the vesicular quality 
increases, the pitch is correspondingly lowered, until, 
at length, no tubularity remains, and the pitch be- 
comes normal. Meanwhile, as the vesicular quality 
increases in the inspiratory sound, the expiratory 
sound is less and less prolonged, high and tubular, 
until it becomes, as in health, short, low, and blowing. 
The broncho- vesicular respiration is an important 
diagnostic sign in all the affections which involve 
partial solidification of lung. In lobar pneumonia, 

9* 



102 AUSCULTATION IN DISEASE. 

as just stated, it denotes the progress made from 
day to day in resolution. It is found also in an 
earlier stage, before the solidification is sufficient 
to give rise to a purely bronchial respiration. It is 
a valuable sign in phthisis, affording evidence, not 
only of the fact of solidification, but of its degree 
and extent. The sign enters into the diagnosis of 
interstitial pneumonia, hemorrhagic infarctus, con- 
densation of lung from the pressure of either liquid, 
air, or a tumor, and from collapse of pulmonary 
lobules. It may be stated, with respect to this sign, 
that it is always present, if the lung be partially 
solidified, provided there be not either suppression 
of respiratory sound, or such a degree of feebleness 
that the distinctive characters are undeterminable. 
As with the bronchial respiration, so with the 
broncho- vesicular, either the inspiratory or the ex- 
piratory sound may be wanting. The characters 
of the sign are then to be determined as they are 
manifested in the sound which is present, namely, 
the combination of the vesicular and the tubular 
quality, with more or less elevation of pitch, if only 
an inspiratory sound be heard, and the amount of 
prolongation, tubularity, and elevation of pitch, if 
there be only an expiratory sound. 

In determining the presence of this morbid sign, 
at the summit of the chest on the right side, it is 
to be borne in mind that the respiratory murmur 
on this side has, in health, as compared with the 
respiratory murmur at the summit on the left side, 
more or less of the characters of the broncho-vesicu- 
lar respiration {vide Normal Broncho-vesicular Eespi- 
ration, page 79). 



MODIFICATIONS OF NORMAL SOUNDS. 103 

Cavernous Respiration. — The modifications which 
constitute the distinctive characters of this sign, 
are produced by the entrance of air into a cavity 
with the act of inspiration, and its exit from the 
cavity with the act of expiration. This passage of 
air into and from a cavity can only take place 
where the walls of the cavity collapse more or less 
in expiration and expand in inspiration. Pulmo- 
nary cavities occur chiefly in cases of phthisis. 
They occur, but with comparative infrequency, as 
a result of circumscribed abscess and gangrene of 
lung. 

A well-marked cavernous respiration has charac- 
ters which are highly distinctive when this sign is 
contrasted, on the one hand, with either the bronchial 
or broncho-vesicular respiration, and, on the other 
hand, w T ith the normal vesicular murmur. These 
distinctive characters relate both to the inspiratory 
and the expiratory sound. The inspiratory sound 
is neither vesicular nor tubular in quality, and the 
pitch is low as compared with the bronchial respi- 
ration. As regards quality, w r e may say of it, as of 
the expiratory sound in the normal vesicular respi- 
ration, it is simply a blowing sound. The expira- 
tory sound has the same quality as the inspiratory, 
and it is lower in pitch. Its duration is variable. 
The intensity of both the inspiratory and the expi- 
ratory sound varies ; intensity does not enter into 
the distinctive characters of this sign more than 
into those of the bronchial and the broncho-vesi- 
cular respiration. These distinctive characters of 
the cavernous respiration, as regards pitch and 
quality, especially of the expiratory sound, were 



104 AUSCULTATION IN DISEASE. 

first pointed out by me in 1852. x Prior to this date 
the bronchial and the cavernous respiration were 
considered as having identical characters, or, at all 
events, as not distinguishable from each other. 
With a practical knowledge of the foregoing char- 
acters distinctive of the cavernous respiration, 
there is no difficulty in discriminating this sign 
from the bronchial respiration. The sign is more 
likely to be confounded with the normal vesicular 
murmur, inasmuch as it differs from the latter only 
in the absence, in the inspiratory sound, of the vesi- 
cular quality. Against this error the student is to 
be cautioned. It is most likely to be made when 
the inspiratory sound is much weakened, and, con- 
sequently, the vesicular quality is less distinctly 
appreciable than when the sound is more or less 
intense. 

A cavernous respiration is limited to a space 
more or less circumscribed, the area corresponding 
to the site and the size of the cavity. Occurring, 
for the most part, in cases of phthisis, it is much 
often er found at the summit than elsewhere over 
the chest. It is not constantly found where there 
is a cavity with flaccid walls. It may be tempo- 
rarily suppressed by the presence of liquid within 
the cavity, and by obstruction of the orifices com- 
municating with bronchial tubes, or of the latter. 
It may be wanting at one moment, and an act of 
expectoration may cause it to reappear. Hence, 
absence of cavity cannot be predicated on the 

1 Prize Essay on Variations of Pitch in the Sounds obtained by 
Percussion and Auscultation. Transactions of the American 
Medical Association, 1852. 



MODIFICATIONS OF NORMAL SOUNDS. 105 

absence of the sign at a single examination. More- 
over, if a cavity be not situated near the pulmonary 
superfices, and solidified lung intervene between it 
and the walls of the chest, the cavernous sign may 
be drowned in a loud bronchial respiration. For 
this reason, while the cavernous sign is positive 
evidence of a cavity, the absence of the sign is not 
proof that a cavity does not exist. 

In some cases of perforation of lung with pneumo- 
thorax, the passage of air to and fro through the 
perforation may give rise to the cavernous respi- 
ration. As a rule, however, under these circum- 
stances, another sign is produced, namely, the am- 
phoric respiration. 

Broncho-cavernous Respiration. — In this sign, as 
the name denotes, the characters of the bronchial 
and the cavernous respiration are combined. These 
characters may be combined in different ways, as 
well as in variable proportions. If a cavity be situ- 
ated in proximity to solidified lung, the quality and 
pitch of the inspiratory and the expiratory sound 
may show an admixture of the characters of the two 
signs, and to a practised ear, the combination is dis- 
tinctly recognizable. This is one of the forms of 
broncho-cavernous respiration ; the sounds are not 
sufficiently high and tubular for bronchial, nor suffi- 
ciently low and blowing for cavernous respiration. 
Another form consists of an inspiratory sound, the 
first part of which is tubular, and the latter part 
cavernous. Examples of this form are not extremely 
infrequent. Still another form is a cavernous inspi- 
ratory, with a bronchial or tubular expiratory sound. 
In the latter form, the bronchial expiration proceeds 



106 AUSCULTATION IN DISEASE. 

from solidified lung situated near the cavity, the in- 
tensity of the sound being sufficient to drown the 
cavernous expiration. 

When, as often happens, a cavity is situated in 
close proximity to, or, it may be, surrounded by 
solidified lung, the cavernous and the bronchial res- 
piration are, as it were, in juxtaposition, and such 
instances offer an excellent opportunity to study the 
points distinguishing these signs from each other; 
and, generally, at a short distance the normal vesi- 
cular murmur may be found, so that both morbid 
signs may be compared with the latter. Within a 
circumscribed area, sometimes, are exemplified the 
characters of the normal murmur, and of the two 
morbid signs just mentioned, together with those of 
the broncho-vesicular respiration. 

Amphoric Respiration. — The term amphoric has a 
significance when applied to auscultatory sounds, 
analogous to that which it has in percussion ; it de- 
notes a musical intonation which may be compared 
to the sound produced by blowing upon the open 
mouth of a decanter or phial. Whenever the respi- 
ratory sound has this intonation, it denotes a space 
containing air which is not expelled with the act of 
expiration. Air in the pleural cavity, with perfora- 
tion of lung, is the physical condition most fre- 
quently represented by this sign. It is a valuable 
diagnostic sign in cases of pneumothorax; but it is 
not always present in that affection, certain accessory 
conditions being requisite, namely, perforation above 
the level of liquid, and an unobstructed communica- 
tion of the bronchial tubes, through the opening, 
with the pleural space containing air. While, there- 



MODIFICATIONS Or NORMAL SOUNDS. 107 

fore, its presence is significant of pneumothorax, its 
absence is by no means sufficient to exclude this af- 
fection. Xot infrequently, it is a sign of a phthisical 
cavity with rigid walls which do not collapse with 
the act of expiration. The same contingencies afreet 
its production here as in cases of pneumothorax. 
\Yhenever amphoric respiration is present, if pneumo- 
thorax be excluded by the absence of the other signs 
which are diagnostic of this affection, the sign is 
proof of the existence of a pulmonary cavity, the 
walls of which are not flaccid. The sign then takes 
the place of the ordinary cavernous respiration which 
has been described. 

The amphoric sound may accompany either respi- 
ration or expiration, or both. 

Shortened Inspiration. — The inspiratory sound is 
somewhat shortened in bronchial or tubular respira- 
tion. This modification enters into the characters 
of that sign, the quality of the sound being tubular, 
and the pitch high. The shortening is due to the 
sound ending before the inspiratory act ends ; the 
sound is said to be unfinished. Shortening of the 
sound occurs, however, when it is not an element in 
the bronchial respiration. The shortening is then 
due to the sound not beginning with the inspiratory 
act; this is distinguished as deferred inspiratory 
sound. A deferred inspiratory sound not tubular in 
quality, but more or less vesicular, and not notably 
raised in pitch, is a sign of pulmonary or vesicular 
emphysema. It is a sign of diagnostic value in that 
connection. 

The student should note the distinctions just 
stated which relate to pitch and quality. Suppose 



108 AUSCULTATION IN DISEASE. 

an inspiratory sound to be present without an ex- 
piratory sound: — if the sound be shortened at the 
end of the inspiration, the pitch high and the quality 
tubular, it is bronchial respiration, denoting com- 
plete or considerable solidification of lung, but if 
the shortening be at the beginning of inspiration, 
the pitch comparatively low, and vesicular quality 
be appreciable, the sign denotes emphysema. The 
differential points thus are, the inspiratory sound 
unfinished or deferred, the pitch high or low, and 
the quality tubular or vesicular. Attention to these 
points is essential in order to avoid error in the 
interpretation of the sign. 

Prolonged JExjriratioji. — The length of the expira- 
tory sound in health varies in different persons. The 
sound is sometimes considerably prolonged : it may 
be nearly as long as the sound of inspiration. There 
is no difficulty in recognizing this as a normal pecu- 
liarity, from the fact that the murmur has the pitch 
and quality of health. An unusual length of the 
expiratory sound, within the range of health, is 
usually observed at the summit of the chest, and 
especially on the right side. It is important to bear 
in mind that at the summit of the chest on the right 
side, and sometimes also on the left side, a prolonged 
expiratory sound, more or less raised in pitch, and 
tubular in quality, may be a normal peculiarity. It 
follows that a prolonged, and even a high and tubu- 
lar expiration at the summit of the chest, must not 
be reckoned as a morbid sign unless it be associated 
with other signs denoting disease. The laws of the 
disparity between the two sides of the chest at the 
summit are to be taken into account (vide p. 79). 



MODIFICATIONS OF NORMAL SOUNDS. 109 

If the expiration be longer on the left than on the 
right side, it is abnormal ; so, also, is a high-pitched 
tubular expiration heard on the left and not on the 
right side. 

The significance of an abnormally prolonged ex- 
piration depends on its pitch and quality. If it be 
high and tubular, it denotes solidification of lung. 
It is, in fact, bronchial respiration. As already 
stated, in bronchial or tubular respiration, the inspi- 
ratory sound is sometimes wanting, and the presence 
of the sign is then to be determined by the char- 
acters, relating to pitch and quality, of the expiratory 
sound. The same statement holds true with respect 
to broncho-vesicular respiration, when this approxi- 
mates to the bronchial. At the summit of the chest, 
the characters of the inspiratory sound, and asso- 
ciated morbid signs, always enable the auscultator 
to determine whether a prolonged high and tubular 
expiration be, or be not, abnormal. A prolonged 
expiration, which is low in pitch and blowing in 
quality, that is, with the characters of health, aside 
from length, may belong to a cavernous expiration. 
This is to be determined by the characters of the 
inspiration, and by other associated signs. Exclusive 
of cavernous respiration, an abnormally prolonged 
expiratory sound of low pitch and non-tubular, 
denotes vesicular emphysema. It is associated then 
with a weakened and deferred inspiratory sound. 
A prolonged expiratory sound, in cases of emphy- 
sema, is invariably low and non-tubular. If it have 
not these characters, it is not a sign of emphysema, 
but belongs to bronchial or broncho-vesicular respi- 
10 



110 AUSCULTATION IN DISEASE. 

ration. Attention to these differential points is to 
be enjoined upon the student. 

A prolonged expiration at the summit of the chest 
on the right side is sometimes incorrectly considered 
to be evidence of phthisis. It is to be recollected, 
in. the first place, that prolongation of this sound 
with a normal pitch and quality, is never evidence 
of solidification of king either from phthisis or any 
other disease; and in the second place, even if the 
pitch be high, and the quality tubular, that it is not 
to be regarded as abnormal, provided the inspiratory 
sound is unchanged, and other signs of disease are 
not present. 

Interrupted Respiration. — To this sign have been 
applied other names, such as jerking, wavy, cogged 
wheel, and by French writers the names entrecoupee 
and saccadee. The modification is either of the inspi- 
ration or of the expiration, or of both. The inspira- 
tory, however, much more frequently than the expi- 
ratory, sound is interrupted. The sound, instead of 
being continuous, is broken into one, two, or more 
parts. This is the characteristic of the sign. If, 
at the same time, there be alterations in pitch and 
quality , the interruption is merely incidental to other 
signs ; namely, the bronchial, broncho-vesicular, or 
cavernous respiration. To constitute it a distinct 
sign, the interruption must be the only appreciable 
change. Thus limited, the sign has but little diag- 
nostic value. 

Interrupted respiration is sometimes found in 
healthy persons. It is confined to the summit of 
the chest, and oftener on the left than the right side. 
Existing without any other signs, therefore, it is not 



MODIFICATIONS OF NORMAL SOUNDS. Ill 

evidence of disease. It is of value only in the diag- 
nosis of phthisis. Associated with other signs, when 
the latter are not marked, it is entitled to a certain 
amount of weight in the diagnosis. 

Interrupted respiratory sounds, of course, occur 
when there is interruption in the respiratory move- 
ments. This happens in cases of pleurisy, pleuro- 
dynia, or intercostal neuralgia. Owing to the pain 
caused by the movements in respiration, the patient 
may breathe, not continuously, but with a series of 
jerking movements. Sometimes interrupted breath- 
ing is observed in persons who are excited or agitated 
when auscultation is practised. In all these in- 
stances, interruption in the respiratory sounds is 
found over the wdiole chest, w T hereas, when it is an 
abnormal sign in cases of phthisis, it is limited to 
the summit on one side of the chest, and there is no 
interruption manifested in the mode of breathing. 

Reviewing the foregoing signs, they may be dis- 
tributed into three classes, as follows: 1st. Signs, 
the distinctive characters of which relate to either 
the absence or the intensity of sound. This class em- 
braces (a) increased intensity of the vesicular mur- 
mur ; (b) diminished intensity of the vesicular mur- 
mur ; and (c) suppression of respiratory sound. 2d. 
Signs, the distinctive characters of which relate es- 
pecially to pitch and quality. In this class belong, 
(a) bronchial or tubular respiration ; (b) broncho- 
vesicular respiration ; (c) cavernous respiration ; (d) 
broncho-cavernous respiration, and (e) amphoric 
respiration. 3d. Signs, the distinctive characters of 
which relate especially to rhythm, namely, (a) 



112 AUSCULTATION IN DISEASE. 

shortened inspiration ; (b) prolonged expiration ; 
and (c) interrupted respiration. 

Adventitious Respiratory Sounds, or Rales. 

Adventitious respiratory sounds, or, adopting the 
French term, rales, are distinguished from the mor- 
bid signs already considered, by the fact that they 
have no analogues in health ; in other words, they 
are not normal sounds abnormally modified, but 
wholly new sounds. A convenient classification of 
these signs is based on the different anatomical situa- 
tions in which they are produced. This classification 
is as follows: 1st. Laryngeal and tracheal rales ; 2d. 
Bronchial rales; 3d. Vesicular rale ; 4th. Cavernous 
rales; 5th. Pleural rales ; and 6th. Indeterminate 
rales. Compared with each other, as regards their 
characters, they admit of being divided into dry and 
moist rales, the latter being evidently due to the 
presence of liquid. 

Laryngeal and Tracheal Rales. — The rales produced 
within the larynx and trachea may be either moist 
or dry. The moist or bubbling sounds are produced 
when mucus or other liquid accumulates in these 
sections of the air tubes. This occurs frequently in 
the moribund state, and the sounds are then known 
as the u death rattles." When not incident to this 
state, they denote either insensibility to the presence 
of liquid, as in coma, or inability to effect the re- 
moval of the liquid by acts of expectoration. The 
sounds are heard at a distance. They exemplify, on 
a large scale, moist or bubbling auscultatory sounds 
which are produced within the bronchial tubes. 
The dry rales produced within the larynx or trachea 



MOIST BRONCHIAL RALES. 113 

are caused by spasm of the glottis, and by diminu- 
tion of the calibre, either at or below the glottis, 
from oedema, exudation, the presence of a foreign 
body, or the pressure of a tumor. The dry sounds 
are distinguished as whistling, wheezing, crowing, 
whooping, etc. They are heard at a distance, and 
they also exemplify auscultatory sounds representing 
analogous conditions in the bronchial tubes. Char- 
acteristic sounds produced at the glottis by spasm 
enter into the diagnosis of certain affections, namely, 
laryngismus stridulus, pertussis, croup, and aneurism 
involving excitation of the recurrent laryngeal nerve. 
Other sounds are due to paralysis of the laryngeal 
muscles. Again, dry sounds, called stridor, pro- 
duced by stenosis of the trachea from the pressure 
of an aneurismal or other tumor, cicatrization of 
ulcers, and morbid growths, are of diagnostic im- 
portance. Although audible without auscultation, 
these different sounds, with reference to the precise 
situation at which they are produced, may some- 
times be studied with advantage by means of the 
stethoscope. 

Moist Bronchial Rales. 

The moist bronchial rales are bubbling sounds 
produced in different branches of the bronchial tree. 
They are sounds of which the "tracheal rattles" 
are an exaggerated type. They may be imitated by 
blowing into liquids through tubes differing in size. 
The bubbles seem to be large or small, according 
to the size of the bronchial tubes in which they are 
produced. Apparent differences in the size of the 
bubbles are distinguished by the names coarse 

10* 



114 AUSCULTATION IN DISEASE. 

and fine. In the primary and secondary bronchial 
branches the moist sounds are relatively qnite coarse ; 
they are less so in tubes of the third or fourth dimen- 
sions ; in smaller tubes they become fine, and in those 
of minute size they become quite fine. Extremely 
fine bubbling sounds constitute what is known as 
the subcrepitant rale, so called because it approaches 
in character to the crepitant rale produced within 
the air vesicles and bronchioles. We may thus 
judge of the size of the bronchial tubes in which 
the rales are produced by their comparative coarse- 
ness or fineness. Frequently, however, coarse and 
fine rales are intermingled, and generally those which 
are either coarse or fine are not uniform, but appear 
to be of unequal size. In all the varieties of the 
moist bronchial rales, the bubbling character of the 
sounds is sufficiently distinctive for their recognition. 
The differentiation of the subcrepitant from the 
crepitant rale alone involves some nice points of dis- 
tinction. 

Coarse bubbling rales sometimes occur in acute 
bronchitis affecting the larger bronchial tubes. Their 
occurrence is exceptional, because, in general, the 
mucus within the tubes does not accumulate suffi- 
ciently and is too consistent for the production of 
bubbling sounds. These rales occur in cases in 
which the mucus is unusually thin and either more 
abundant than usual or an accumulation takes j3lace 
in consequence of inability to expectorate freely. 
These conditions are wanting in the majority of the 
cases of ordinary acute bronchitis. A muco-purulent 
liquid in cases of chronic bronchitis is better suited 
for the production of bubbling sounds than simple 



MOIST BRONCHIAL RALES. 115 

mucus. Moreover, coarse rales are heard oftener in 
children than in adults, because the former do not 
voluntarily expectorate as freely as the latter. 
Serous transudation (bronchorrhoea) into tubes of 
large size may give rise to coarse bubbling rales, and 
also the presence of blood in some cases of profuse 
hemorrhage. In bronchitis and bronchorrhoea the 
rales are heard on both sides of the chest. The 
bubbling rales, whether coarse or fine, are heard 
either with the act of inspiration or of expiration, 
or with both acts. 

Fine bubbling sounds and the subcrepitant rale 
occur in various pathological connections. The 
characters of the subcrepitant rale are to be borne 
in mind with reference to the discrimination from 
the crepitant. The most distinctive character is the 
moist sound or bubbling ; this is sufficiently appre- 
ciable. Other characters are the occurrence fre- 
quently, but not constantly, in expiration as well as 
in inspiration, and the inequality of the fine bub- 
bling sounds. 

The subcrepitant rale, existing over the chest on 
both sides, is diagnostic of bronchitis affecting; the 
smaller bronchial tubes (capillary bronchitis), when 
taken in connection with other signs and the symp- 
toms. The rale exists on both sides, because this, 
as well as bronchitis affecting the larger tubes, is a 
bilateral affection. The sign is of great practical 
value in that pathological connection. The rale also 
occurs on both sides, and is more or less diffused in 
pulmonary oedema. This pathological connection is 
shown by the associated physical signs, together 
with the symptoms. In so-called capillary bron- 



116 AUSCULTATION IN DISEASE. 

chitis, the bubbling is due to the presence of thin 
mucus, and in pulmonary oedema to serous transuda- 
tion within the small bronchial ramifications. 

Fine bubbling or a subcrepitant rale has other 
pathological connections, as follows: — 

1. It occurs in lobar pneumonia during the stage 
of resolution. Here it is due to the presence of 
mucus from a bronchitis limited to the affected 
lobe or lobes, and, in a measure, to liquefied pneu- 
monic exudation. It is considered as denoting 
commencing and progressing resolution in pneu- 
monia. Sometimes it is intermingled with rales 
which are more or less coarse. 

2. In circumscribed pneumonia, hemorrhagic 
infarctus, and pulmonary apoplexy, the fine or sub- 
crepitant rale, often associated with those which are 
more or less coarse, denotes the presence of mucus or 
blood within the bronchial tubes. The rales are 
localized in a space, or in spaces, corresponding to 
the situation and extent of the affection. 

3. During and shortly after a hemoptysis, fine 
rales limited to a particular situation are sometimes 
heard, proceeding from blood in the small bronchial 
tubes, and indicating the place of the hemorrhage. 

4. A purulent liquid admits of bubbling much 
more readily than mucus ; hence, in cases of chronic 
bronchitis with an expectoration of pus, fine and 
coarse bronchial rales are more frequent than in acute 
bronchitis. Pus, also, may be present within bron- 
chial tubes of small size, not as a product of bron- 
chitis, but from the evacuation of an abscess of either 
the pulmonary parenchyma, of the liver, or some 



MOIST BRONCHIAL RALES. 117 

other adjacent part, and from perforation of lung in 
some cases of empyema. 

5. In the different stages of phthisis, moist bron- 
chial rales are usually present. The liquid in the 
tubes, if the disease be advanced, is derived, in part, 
from associated bronchitis, and, in part, from lique- 
fied tuberculous exudation. The bubbling sounds 
may be more or less coarse or fine, and both are often 
intermingled. Early in the disease, before softening 
of the exudation has taken place, fine bubbling or 
the subcrepitant rale, limited to the summit of the 
chest, is an imnortant diagnostic sign. It belongs 
among the accessory physical signs on which the 
diagnosis may depend. Here the liquid is derived 
from a coexisting circumscribed bronchitis. 

In cases of fibroid phthisis, or cirrhosis of lung, 
moist rales, coarse and fine, are generally more or 
less abundant, and diffused over the whole, or the 
greater part, of the chest on the affected side. 

In the foregoing account of the moist bronchial 
rales, the subcrepitant rale is not reckoned as a sign 
distinct from fine bubbling sounds. Inasmuch as 
the mechanism and the significance are the same, and 
it is not easy to draw a line of demarcation between 
the two, the distinction is unimportant. It is suffi- 
cient to bear in mind that very fine bubbling sounds 
are called subcrepitant, because they are somewhat 
analogous to the crepitant rale. The points which 
distinguish the latter are, however, well marked, as 
w^ill appear when the characters of that sign are 
considered. The moist rales are often called mucous 
rales. This name is obviously inappropriate, since, 



118 AUSCULTATION IN DISEASE. 

not only are the sounds produced by other liquids 
than mucus, but other liquids are best suited for 
their production, especially in the large and niedium- 
sized tubes. 

The moist bronchial rales, whether coarse or fine, 
vary in pitch accordingly as the lung surrounding 
the tubes in which they are produced is, or is not, 
solidified. If the lung be solidified, the pitch is 
high ; if there be no solidification, the pitch is com- 
paratively low. Thus, the pitch of the rales is high 
in the second stage of pneumonia and in phthisis 
with considerable solidification, whereas the pitch is 
low in bronchitis and pulmonary oedema. If, there- 
fore, the respiratory sound be suppressed, it is easy 
to determine by the pitch of these rales whether the 
lung be solidified or not, and to judge measureably 
of the degree of solidification. Attention to the 
pitch in this connection is sometimes of value in 
diagnosis. 

Dry Bronchial Rales. 

All adventitious sounds, which are not moist, 
produced within the air tabes below the trachea, 
are embraced under the name dry bronchial rales. 
The sounds are numerous and varied in character. 
They are often musical notes. Frequently they are 
suggestive of certain familiar sounds, such as the 
chirping of birds, the cry of a young animal, snoring 
in sleep, cooing of pigeons, humming of the mos- 
quito, the note of the violoncello, etc. etc. They 
are often heard at a distance, and characterized 
as wheezing sounds. An interrupted, or clicking 



DRY BRONCHIAL RALES. 119 

sound is not uncommon. All these varieties are 
practically unimportant, and it would be a needless 
refinement to consider particular varieties as distinct 
signs. The only distinction which it is desirable to 
make is into the sibilant and sonorous rales. This 
distinction is based on difference in pitch ; sibilant 
rales are high, and sonorous rales are low in pitch. 
As a rule, the sibilant rales are produced in the small 
and the sonorous rales in the larger sized bronchial 
tubes. The sounds may accompany either inspiration 
or expiration, or both. The sibilant and sonorous 
rales are often intermingled. There may be sibilant 
rales with inspiration, and sonorous rales with expi- 
ration, within the same situation. Moreover, these 
rales are found often to vary from minute to minute, 
being at one instant sibilant and at another sonorous. 
Their recognition involves no difficulty. There are 
no other adventitious sounds with which they are 
liable to be confounded. 

The physical condition represented by the dry rales 
is generally a narrowing of the air tubes at certain 
points, and especially in consequence of spasm of the 
bronchial muscular fibres. The latter constitutes 
the essential pathological condition in a paroxysm 
of asthma; and in this affection the dry rales are 
always marked. Their diagnostic importance re- 
lates chiefly to asthma. Both sibilant and sonorous 
rales are present and diffused over the entire chest. 
Wheezing sounds with expiration are heard by the 
patient, and by others at a distance. A single 
paroxysm of asthma affords an opportunity for the 
student to observe all the varieties and fluctuations 
of these rales. Taken in connection with other 



120 AUSCULTATION IX DISEASE. 

signs and the symptoms, the rales are pathognomonic 
of asthma. 

More or less spasm of the bronchial muscnlar 
fibres occurs in certain cases of bronchitis, without 
being sufficiently great and extensive to give rise to 
a paroxysm of asthma, or even any embarrassment 
of respiration. Under these circumstances, the rales 
are less marked and diffused. An asthmatic element 
may be said to enter, more or less, into these cases. 
Narrowing of bronchial tubes by tenacious mucus 
which gives rise to no bubbling sounds, and, perhaps, 
unequal swelling of the mucous membrane, may also 
occasion sibilant and sonorous rales. 

Dry rales at the summit of the chest are not in- 
frequent in cases of phthisis, due to spasm, the 
presence of mucus, or to swelling of the mucous mem- 
brane. They are sometimes quite annoying to 
phthisical patients. 

Clicking sounds are suggestive of the sudden sepa- 
ration of tenacious mucus from the walls of the bron- 
chial tubes. These are sufficiently common in bron- 
chitis and in phthisis. 

Vesicular or Crepitant Rale. 

This is the only vesicular rale. It is usually con- 
sidered to be produced within the air vesicles, bat, 
probably, the terminal bronchial tubes or bronchi- 
oles participate in its production. 

It is to be distinguished from very fine bubbling 
sounds, or the subcrepitant rale. The points of 
distinction are as follows: The sounds are not moist 
but dry; they are crackling, not babbling in cha- 
racter. They may be defined to be very fine, dry, 



VESICULAR OR CREPITANT RALE. 121 

crackling sounds. This point of difference is very 
distinctive. There are, however, other differential 
points. The crackling sounds are equal, whereas, 
fine bubbling sounds are unequal, that is, they give 
the impression of bubbles of unequal size. The cre- 
pitating sounds are heard at the end of the inspira- 
tory act, and especially at the end of a forced inspira- 
tion, the subcrepitant rale, on the other hand, being 
heard often with or near the beginning of inspiration, 
and, perhaps, ceasing before the end of the inspira- 
tory act. Another distinctive feature is the abrupt 
development of the crepitant rale; a shower of 
crackles, as it were, springs up at the end of a forced 
inspiration. Finally, the rale is never heard in ex- 
piration. The apparent exceptions to this statement 
are instances in which the crepitant and the sub- 
crepitant rale are associated. This is not very in- 
frequent, and, with a practical knowledge of the 
characters of each, it is by no means difficult to ap- 
preciate the combination of the two signs. In fact, 
the combination affords an excellent opportunity to 
illustrate the distinctive characters of each ; the fi ne 
bubbling at or near the beginning of inspiration, 
followed by the fine crackling at the end of this act, 
and the former reproduced in the act of expira- 
tion. 

There are various modes in which the crepitant 
rale may be imitated, for examples, rubbing together 
a lock of hair near the ear, throwing fine salt upon 
live coals or into a heated vessel, isniiitinff a train of 
gunpowder, and alternately pressing and separating 
the thumb and finger moistened with a solution of 
gum-arabic and held near the ear. A perfect repre- 
11 



122 AUSCULTATION IN DISEASE. 

sentation is afforded by squeezing a piece of an arti- 
ficial preparation known as the India-rubber sponge, 
and observing the sound produced by the separation 
of the walls of the interstices when the piece expands 
from its elasticity. This preparation, which has now 
gone out of use, exemplified the true mechanism of 
the sign as described, first, by the late Dr. Carr, of 
Canandaigua, 1ST. Y., in an article published in the 
American Journal of Medical Sciences in October, 
1842. 1 

The crepitant rale is the diagnostic sign of pneu- 
monia. It very rarely occurs in any other patho- 
logical connection. Of all respiratory signs, this is 
most entitled to be called pathognomonic. It be- 
longs especially to the first stage of acute pneumonia. 
It is not invariably present, but it occurs in the 
majority of cases of acute pneumonia. In the 
second stage, or the stage of solidification, the rale 
generally disappears. It not infrequently is repro- 
duced in the stage of resolution, and it is then called 
the returning crepitant rale. In the latter stage it 
is often found in combination with the subcrepitant 
rale. The practical value of this sign relates chiefly 
to the diagnosis of pneumonia. 

It is stated that the crepitant rale is sometimes 
found in cases of pulmonary oedema, and during or 
directly after an attack of hemoptysis. If it ever 
occur in these cases, the instances must be extremely 
rare. The statement is perhaps based on the occur- 
rence of the subcrepitant, this being confounded with 

1 Vide article by the author in the New York Monthly Med. 
Journ. for Feb. 1869. 



CAVERNOUS OR GURGLING RALE. 123 

the crepitant rale. It occurs transiently under the 
following circumstances: a patient who has been 
confined for some time in bed, lying on the back, 
and much enfeebled with any disease, if suddenly 
raised to a sitting posture and auscultated, a crepi- 
tant rale is often found on the posterior aspect of 
the chest at the end of a forced inspiration. The 
rale disappears after a few forced inspirations. It is 
heard, not on one side only, but on both sides. The 
explanation is, that during the recumbent posture 
continued for some time, and the patient breathing 
feebly, enough of the air vesicles and bronchioles 
become agglutinated by means of a little sticky 
transudation to give rise to crackling sounds in a 
few forced inspirations. It may be of use to men- 
tion that if the stethoscope be applied to the anterior 
surface of a chest much covered with hair, the move- 
ments of the pectoral extremity of the instrument 
in the act of inspiration may produce a sound iden- 
tical with the crepitant rale. 

A crepitant rale at the summit of the chest, with- 
in a circumscribed space, is one of the accessory 
signs of phthisis. It denotes a circumscribed pneu- 
monia which clinical experience shows to be gene- 
rally secondary to phthisis; hence the diagnostic 
significance of the sign. 

Cavernous or Gurgling Rale. 

A pulmonary cavity of considerable size, contain- 
ing a certain quantity of liquid, and communicating 
freely with bronchial tubes, furnishes a rale which 
is characteristic. The character of the sound is ex- 
pressed as fully as possible by the term gurgling. 



124 AUSCULTATION IN DISEASE. 

The sound is produced "by large bubbling and the 
agitation of the liquid within the cavity. It may 
be compared to the sound produced by the boiling of 
a liquid in a flask or large test-tube. The sound 
is sometimes high pitched and amphoric, but gene- 
rally it is low in pitch. It is heard with more or 
less intensity within a circumscribed space almost 
invariably at or near the summit of the chest ; but, 
if intense, the sound is diffused, and it may be some- 
times heard at a distance. Its diagnostic import- 
ance relates to the advanced stage of phthisis. The 
rale is heard chiefly or exclusively in the act of 
inspiration. It may be produced by the act of 
coughing sometimes with greater intensity than by 
respiration. 

Pleural Rales. Friction Sounds. Metallic Tinkling. 
Splashing. 

The signs embraced under the name pleural rales 
are, 1st. Sounds produced by the rubbing together 
of the pleural surfaces, and hence called friction 
sounds; 2d. Metallic tinkling; and 3d. Splashing 
or succussion sounds. 

Friction Sounds. — Movements of the pleural sur- 
faces upon each other take place in inspiration and 
expiration ; but in health these movements occasion 
no sound. Sounds are produced when the surfaces 
are covered with a glutinous matter preventing the 
normal continuous, unobstructed movements, and 
when the surfaces are roughened with dense lymph 
or other morbid products. The sounds are generally 
interrupted, that is, two, three, or more sounds occur 
during the act of inspiration or expiration, or during 



FRICTION" SOUNDS. 125 

both acts. The intensity of the sounds varies much 
in different cases. A slight grazing sound only may 
he heard, or, on the other hand, the sounds may he 
so loud as to he heard by the patient, and by others 
at a distance. The character of the sounds is vari- 
able. The slight rubbing or grazing character may 
be imitated by placing over the ear the palmar sur- 
face of one hand, and moving over its dorsal sur- 
face slowly the pulpy portion of a finger of the other 
hand. In some instances, however, the rough char- 
acter of the sounds is expressed by such terms as 
rasping, grating, and creaking. In these instances 
the sounds denote density of the morbid product 
which roughens the pleural surfaces. In connection 
with very rough friction sounds, vibration of the 
walls of the chest or fremitus is sometimes perceived 
by palpation. 

Aside from the character of the sounds as just 
stated, they are distinguised by their apparent near- 
ness to the ear ; they seem sometimes to be produced 
upon the surface of the chest. They are sometimes 
intensified by firm pressure of the stethoscope upon 
the chest. After a little practical knowledge of 
these sounds, they can hardly be confounded with 
any other rales. 

Pleuritic friction sounds generally denote pleurisy. 
In cases of pleurisy with effusion, slight rubbing or 
grazing is sometimes heard before much liquid accu- 
mulates within the pleuritic cavity. The physical 
conditions, however, after the effusion has been 
removed, are much more favorable for the produc- 
tion of friction sounds, and they are often now 
rough in character. They may be transient, or 

11* 



126 AUSCULTATION IN DISEASE. 

they may continue for a considerable period, their 
duration depending on the arrest of the movements 
of the pleural surfaces by means of either agglutina- 
tion with lymph, or adhesion from the growth of 
areolar tissue. 

Pleuritic friction sounds occur not infrequently 
in cases of pneumonia, denoting, in this connection, 
coexisting pleurisy. 

Slight rubbing or grazing at the summit of the 
chest is one of the accessory signs of phthisis. It 
denotes a circumscribed, dry pleurisy which, as 
clinical experience shows, is generally secondary to 
phthisis, and, hence, the diagnostic significance of 
the sign. 

In the foregoing instances in which friction sounds 
are stated to occur, their significance relates to pleu- 
risy. In some rare instances the sounds are pro- 
duced by miliary tubercles or carcinomatous tumors 
projecting beyond the plane of the visceral pleural 
surface, without pleuritic inflammation. 

Metallic Tinkling. — This is a vocal as well as a 
respiratory sign. It is also produced by acts of 
coughing, and sometimes by the act of deglutition. 
The name expresses the distinctive character of the 
sign. It consists in a series of tinkling sounds of a 
high pitched, silvery or metallic tone. The number 
of sounds varies from a single sound, to two, three, 
or more sounds, during an act of either inspiration 
or expiration. It occurs irregularly, that is, it is 
not present in every act of breathing, but is heard 
at variable intervals. It may sometimes be produced 
by forced, when it is not heard in tranquil, breathing. 
The sounds can only be confounded with tinkling 



SPLASHING. 127 

sounds sometimes produced within the stomach. 
The latter, however, are easily discriminated by their 
situation, and the absence of associated signs de- 
noting the affections of the chest in which the sign 
occurs. 

Metallic tinkling is the sign of pneumothorax 
with perforation of lung. In the great majority of 
the cases in which it is found, it is diagnostic of 
this affection. It is, however, always associated 
with other physical signs corroborative of the diag- 
nosis. 

It is a rare sign, in cases of phthisis, of a large 
cavity, the conditions for its production being analo- 
gous to those in pneumo-hydrothorax, namely, a 
space of considerable size containing air and liquid, 
the space communicating with bronchial tubes. 

Splashing ; or, Succussion Sounds. — This sign is 
produced by succussion, which is reckoned as one 
of the different methods of physical exploration. 
Sounds thus produced are not infrequently heard at 
some distance ; generally, however, succussion is 
practised while the ear is applied to the chest, so 
that, properly enough, the sign may be embraced 
among the auscultatory signs, although not pro- 
duced by respiration. 

Splashing is pathognomonic of one affection, 
namely, pneumo-hydrothorax. It is especially 
valuable as a sign of that affection because it is 
almost invariably available. The instances are 
extremely few in which the sign is wanting when 
air and liquid are contained in the pleural cavity. 
It is obtained by jerking the body of the patient 



123 AUSCULTATION" IN DISEASE. 

with a quick, somewhat forcible movement, the ear 
being very near or in contact with the chest. 

The sound is like that produced when a bottle, 
partially filled with liquid, is shaken. The sound 
is often high pitched and amphoric in quality. The 
only liability to error is in confounding with this 
sign, splashing produced within the stomach. At- 
tention to other signs will always protect against 
this error. 

Indeterminate Bales. — Under this head may be 
embraced some sounds sufficiently recognizable, but 
indeterminate as regards the rationale of their pro^ 
duction and the physical conditions which they 
represent. They may be designated crumpling and 
crackling sounds. The former are probably due to 
pleuritic rubbing, and the latter to the separation of 
some slightly adherent air vesicles or bronchioles. 
Their diagnostic value relates only to the early stage 
of phthisis. In conjunction with other signs, any 
indeterminate rale, if limited to the summit of the 
chest, and especially to one side, has some weight in 
the diagnosis. Crumpling and crackling sounds, 
however, are not uncommon in healthy persons at 
the end of forced inspiration. The fact of their 
presence at both summits, and the absence of other 
morbid signs, are the grounds for not considering 
them as evidence of disease. They are found in 
health, especially if the binaural stethoscope be em- 
ployed. Their diagnostic significance, thus, depends 
on limitation to the summit of the chest or one side, 
and association with other signs pointing to incipient 
phthisis. 



BKONCHOPHONY. 129 

Vocal Signs of Disease. 

The vocal signs of disease, with the exception of 
metallic tinkling, which is a vocal as well as respira- 
tory sign, may all he considered as abnormal modifi- 
cations of the normal vocal resonance and of the 
normal bronchial whisper. The student must, there- 
fore, be familiar with the distinctive characters of 
these two normal signs before he is prepared to enter 
upon the study of the abnormal modifications {vide 
pages 82 and 87). He must bear in mind the facts 
which have been presented in relation to the normal 
vocal fremitus {vide page 82). The rules given for 
auscultation of the voice are also to be observed {vide 
page 81). Embracing the abnormal modifications of 
the loud voice, the whisper and fremitus, the follow- 
ing are the signs to be considered : Bronchophony ; 
Whispering Bronchophony ; ^Egophony ; Increased 
Vocal Resonance ; Increased Bronchial Whisper ; 
Cavernous Whisper ; Pectoriloquy ; Amphoric Voice 
or Echo ; Diminished and Suppressed Vocal Reso- 
nance ; Diminished and Suppressed Vocal Fremitus 
and Metallic Tinkling. 

Bronchophony. 

Bronchophony has the same import as bronchial 
or tubular respiration. Like the latter sign, it 
represents complete or considerable solidification of 
lung. Generally the two signs are associated, but 
either may be present without the other. 

The characters which are distinctive of broncho- 
phony, as compared with the normal vocal resonance, 
are these: The vocal sound seems concentrated, in 
most cases near the ear, and the pitch is more or less 



130 AUSCULTATION IN DISEASE. 

raised. These characters are in contrast with the 
diffusion, distance, and lowness of pitch of the nor- 
mal vocal resonance. The intensity of the sound is 
variable ; it may be greater or less than the intensity 
of the normal resonance. A concentrated, high- 
pitched sound, however feeble, is not less a sign of 
complete or considerable solidification of lung, that 
is, it is not less bronchophony, than when the sound 
is intense. 

Yocal fremitus is always to be discriminated from 
vocal resonance. The fremitus associated with bron- 
chophony may, or may not, be greater than the fre- 
mitus of health. Not infrequently the fremitus is 
less than in health. 

It is to be borne in mind that in some healthy 
persons bronchophony exists at the summit of the 
chest, especialh 7 on the right side, over the primary 
bronchus. Existing alone in this situation, it may 
not be abnormal. 

Representing complete or considerable solidifica- 
tion of lung, this sign occurs in the different affec- 
tions in which bronchial or tubular respiration has 
been seen to occur (vide page 98), namely, lobar 
pneumonia, phthisis, chronic or fibroid pneumonia, 
condensation of lung from either pleuritic effusion, 
the accumulation of air in the pleural cavity or the 
pressure of a tumor, collapse of pulmonary lobules, 
coagulation of blood within the air vesicles, and 
carcinoma of lung. 

For the production of bronchophony, a less degree 
of solidification is requisite than for the production 
of bronchial or tubular respiration. Hence, bron- 
chophony may be associated with a broncho-vesicular, 



-3EG0PH0NY. 131 

as well as with a purely bronchial, respiration. This 
is illustrated in the resolving stage of pneumonia. 
When resolution has progressed sufficiently for the 
bronchial to give place to the broncho-vesicular res- 
piration, well-marked bronchophony is often found 
to continue, ceasing at a later period in the resolving 
stage. 

The apparent nearness to the ear of the vocal sound 
in bronchophony is wanting if a certain quantity of 
liquid intervene between the solidified lung and the 
walls of the chest at the situation auscultated. The 
voice under these conditions seems to be more or less 
distant. This difference is readily appreciated. With 
this apparent distance of the bronchophonic voice, in 
some instances is associated the modification which 
is characteristic of another sign, namely, segophony. 

Whispering Bronchophony. 

The characters of this sign correspond to those 
of the expiratory sound in the bronchial or tubular 
respiration {vide p. 98). The sound is more or less 
intensified, high in pitch, and tubular in quality. 
If the patient pronounce numerals in a forced whis- 
per, the characters are generally more marked than 
in the expiratory sound in forced breathing. The 
significance of this sign is the same as that of the 
bronchial or tubular respiration, and of broncho- 
phony with the loud voice. 

iEgophony. 

This sign is a modification of bronchophony. 
As regards concentration and pitch, it has the char- 
acters of bronchophony, the distinctive features 



132 AUSCULTATION IN DISEASE. 

being apparent distance from the ear, and a tremu- 
lousness or a bleating tone. From the latter the 
name is derived, the term signifying the cry of the 
goat. The features which distinguish the sign from 
bronchophony are readily enough appreciated, and it 
represents a physical condition added to solidification 
of lung. This physical condition is the presence of 
liquid effusion. The sign is rarely present in cases 
of large effusion. It occurs usually when the chest 
is about half filled with liquid, and the lung at the 
level of the liquid is sufficiently condensed to give 
rise to bronchophony. This condition, under these 
circumstances, involves agglutination of luno; above 
the portion condensed by pressure. The sign also 
sometimes occurs in cases of plenro-pneumonia, the 
solidification in these cases heing due to pneumonic 
exudation. As a sign of liquid effusion it possesses 
diagnostic value, although, owing to the fact that 
the existence of effusion is easily determined by 
other signs, it may be said to be superfluous. 

Increased Vocal Resonance and Fremitus. 

The distinctive character of this sign is an increase 
of the intensity of the resonance without notable 
change in other respects. The resonance ma} 7 be 
more or less intensified, but it is distant, diffused, 
and comparatively low in pitch ; in other words, the 
characters of bronchophony are wanting. The dif- 
ferential points between bronchophony and increased 
resonance should be clearly apprehended, bearing in 
mind that the intensity of the sound in broncho- 
phony may, or may not, be greater than the normal 
resonance. 



INCREASED VOCAL RESONANCE. 133 

Increased vocal resonance occurs when the lung is 
solidified, the solidification not sufficient in degree 
to produce bronchophony. Lung slightly or mode- 
rately solidified gives rise to an increase of intensity ; 
if the solidification become considerable or complete, 
bronchophony takes the place of the simple increase 
of intensity. Thus, at an early period in pneumonia, 
increased vocal resonance precedes bronchophony; 
and in the stage of resolution the reverse of this 
takes place, namely, increased vocal resonance fol- 
lows bronchophony, the latter ceasing when resolu- 
tion has progressed to a certain extent. 

Contrary to what would perhaps be anticipated, 
in the instances just cited, the intensity of the sound 
when bronchophony is present may be not only not 
increased, but diminished below that of health ; that 
is, in the first stage of pneumonia, the increased in- 
tensity may cease when bronchophony occurs, and 
return when bronchophony disappears. 

Increase of the vocal resonance, occurs in connec- 
tion with pulmonary cavities. Over a cavity of 
considerable size situated near the superficies of the 
lung, the vocal resonance is sometimes extremely 
intense without any bronchophonic characters. The 
latter, if present, denote considerable solidification 
either around the cavity, or between it and the walls 
of the chest. From the presence or the absence of 
bronchophonic characters with greatly increased 
intensity of resonance, the auscultator can judge 
whether the cavity be, or be not, in proximity to 
considerable solidification of lung. 

Irrespective of the cavernous stage of phthisis, 
the sign is of diagnostic importance in the different 
12 



134 AUSCULTATION IN DISEASE. 

affections which involve moderate or slight solidifica- 
tion of lung, namely, pneumonia early in the disease 
and in the stage of resolution, phthisis, over the com- 
pressed lung in pleurisy with moderate effusion, col- 
lapse of pulmonary lohules, hemorrhagic infarctus, 
and carcinoma of lung. Into the diagnosis of all these 
affections, both bronchophony and increased vocal 
resonance enter ; the former, when solidification is 
considerable or complete, and the latter when it is 
slight or moderate. Increased vocal resonance is 
especially valuable in the diagnosis of early or in- 
cipient phthisis. An abnormal resonance, however 
slight, at the summit of the chest on one side, is an 
important sign in that affection. In determining 
an abnormal resonance on the right side, either at 
the summit or elsewhere, allowance must always be 
made for the normally greater resonance on this 
side. 

Increased vocal resonance has the same import as 
the broncho-vesicular respiration. These two signs, 
however, are not always in the same proportion ; 
that is, the characters of the latter may be marked 
out of proportion to the amount of the increase of 
the vocal resonance, and vice versa. 

Increased vocal fremitus generally accompanies 
increased vocal resonance, and it denotes solidifica- 
tion of lung. Fremitus, however, and resonance are 
not always in equal proportion, that is, either may 
be increased more than the other. An increased 
fremitus is sometimes of value in the diagnosis of 
phthisis. The greater fremitus on the right side of 
the chest is always to be borne in mind, and due 



INCREASED BRONCHIAL WHISPER. 135 

allowance is to be made for this disparity in deter- 
mining that the fremitus is increased. 

Increased Bronchial Whisper. 

The significance of this sign is the same as that 
of increased vocal resonance and the broncho- vesicu- 
lar respiration ; it represents the same physical con- 
dition as the two latter signs, namely, solidification 
of lung, greater or less, but below the degree requi- 
site to give rise to bronchophony and bronchial 
respiration. Its diagnostic application is, therefore, 
involved in the same pulmonary affections. 

The characters of the sign are those which belong 
to the expiratory sound in the broncho-vesicular 
respiration. They consist, therefore, of increase of 
intensity and length, a quality more or less tubular, 
and the pitch raised, these modifications of the nor- 
mal expiratory sound varying in degree between 
the slightest appreciable morbid change and a 
close approximation to the bronchophonic whisper. 
The modifications in degree correspond to the 
degree of solidification. To appreciate the charac- 
ters of this sign, it must be studied in comparison 
with those of the normal bronchial whisper in dif- 
ferent portions of the chest. The most important 
of the diagnostic applications of the sign is in cases 
of phthisis in its early stage. In this application, 
the points of normal disparity between the two sides 
of the chest at the summit are to be borne in mind, 
and due allowance made for them (vide page 88). 

A greater intensity of the bronchial whisper at 
the right summit is not evidence of disease ; but 
greater intensity at the left summit is always abnor- 



136 AUSCULTATION IN DISEASE. 

mal. As a rule, the pitch of the normal bronchial 
whisper at the left, is higher than that at the right 
summit ; if, therefore, with a greater intensity of 
the whisper at the right summit, it be a matter of 
doubt whether it denote disease or not, when the 
pitch is higher at this summit, it is to be considered 
as morbid. 

Cavernous Whisper.— The characters distinctive 
of the cavernous whisper are those of the expiratory 
sound in the cavernous respiration, namely, lowness 
of pitch, and the quality blowing, that is, non-tubu- 
lar. The intensity and the duration of the sound 
are variable. It is limited to a circumscribed space 
corresponding to the situation and size of the 
cavity. I^ot infrequently the characters of the sign 
are brought into contrast with those of whispering 
bronchophony, or increased bronchial whisper, these 
latter signs existing in close proximity, and repre- 
senting solidification of lung in the immediate 
neighborhood of the cavity. The diagnostic appli- 
cation of this sign is chiefly to advanced phthisis. 

Pectoriloquy. — Id pectoriloquy , not merely the voice, 
but the speech, is transmitted through, the chest ; 
the auscultator recognizes words uttered by the 
patient. The student, however, must not expect to 
be able to carry on a conversation with the patient 
by means of the stethoscope. Often single words 
only can be recognized. To make sure that these 
are transmitted through the chest, care must be 
taken to exclude their direct transmission from the 
patient's mouth, and the auscultator should not 
know beforehand the words which are to be spoken. 
If these rules be not observed, the auscultator may 



AMPHORIC VOICE OR ECHO. 137 

err in supposing that the words are transmitted 
through the chest. When auscultation is practised 
with one ear, the other should he closed. 

The speech with either the loud or the whispered 
voice may be transmitted, the latter, distinguished as 
whispering pectoriloquy, being much more frequent 
than the former ; moreover, in determining whisper- 
ing pectoriloquy, there is less liability to error in 
mistaking the perception of words coming directly 
from the mouth for the transmission through the 
chest. In the production of this sign, much depends 
on the distinctness with which words are articulated 
by the patient. 

Pectoriloquy belongs among the cavernous signs ; 
but it is by no means exclusively the sign of a cavity ; 
the speech may also be transmitted by solidified lung. 
It is easy to determine in any case whether the sign 
denotes a cavity or solidified lung. If, with trans- 
mitted speech, the voice have the characters of bron- 
chophony, the sign represents solidification of lung ; 
if, on the other hand, the characters of bronchophony 
be wanting, the sign represents a cavity. These 
statements apply equally to the loud and to the 
whispered voice. Of course, associated signs will 
be likely to show whether a cavity exists or not. 
It is to be added that a cavity and solidification of 
lung existing together, may conjointly be concerned 
in the production of the sign. 

Amphoric Voice or Echo. — This sign is identical 
in character with amphoric respiration, with which 
it is usually associated {vide page 106). The amphoric 
intonation may accompany the loud voice and the 
whisper; generally, it is more appreciable or marked 

12* 



138 AUSCULTATION IX DISEASE. 

with the latter. Its significance is the same as that 
of amphoric respiration. As a rule, it rej)resents the 
conditions in pneumothorax, namely, a large space 
filled with air and perforation of lung. In this 
affection it is associated with other signs which suf- 
fice for a prompt and positive diagnosis. It is not 
invariably found in pneumothorax, and it may be 
present in a case at one time and wanting at another 
time, its production being dependent on the perfora- 
tion being above the level of liquid, if the latter 
exist, and on the bronchial tubes leading to the 
perforation being unobstructed. When not associated 
with other signs which are diagnostic of pneumo- 
thorax, or pneumo-hydrothorax, it denotes a phthisi- 
cal cavity of considerable size. It is not infrequently 
a sign of a phthisical cavity w T ith rigid walls and 
communicating freely with bronchial tubes. It has 
this significance whenever pneumothorax can be 
excluded ; and the associated signs in the latter 
affection are such that its exclusion is always prac- 
ticable. 

The amphoric sound sometimes is observed to 
follow the oral voice ; hence, the name amphoric 
echo. 

Diminished and Suppressed Vocal Resonance. — 
Diminution and suppression of the normal vocal 
resonance occur especially when the j3leural cavity 
contains either liquid or air. Whenever the lungs 
are not in contact with the walls of the chest, the 
vocal resonance, as a rule, is either notably lessened 
or wanting. The sign is, therefore, of value in diag- 
nosis in cases of pleurisy with effusion, empyema, 
hydrothorax, and pneumothorax. When the pleural 



DIMINISHED VOCAL RESONANCE. 139 

cavity is partially filled with liquid, there is dimi- 
nution or suppression of the resonance from the level 
of the liquid downward ; and, generally, just above 
the level of the liquid, the resonance is increased, 
owing to condensation of the lung. The sign is well 
illustrated by the contrast in such cases above and 
below the level of the liquid. The changes of the 
level of the liquid with changes in position of the 
body, may be as well demonstrated by means of 
vocal resonance as by percussion. 

The practical importance of diminished and sup- 
pressed vocal resonance relates chiefly to the diagnosis 
of the affections just named. In this application, 
however, the associated signs must be taken into 
account. The vocal resonance may be diminished or 
suppressed when the lung is completely solidified in 
the second stage of pneumonia ; also in pulmonary 
oedema, and over the site of an intra-thoracic tumor. 

If the vocal resonance be normal, that is, neither 
increased nor diminished, we are warranted in ex- 
cluding all the affections which have been named. 
If this statement is to be qualified in any measure, 
the exceptional instances are so rare that, practically, 
they may be disregarded. 

Diminished vocal resonance may be found over a 
pulmonary abscess before the pus is evacuated, and 
over a cavity filled with liquid. The sign is then 
limited to a circumscribed space. Obstruction of a 
bronchial tube diminishes resonance in so far as the 
column of air is a medium for the conduction of 
vocal sound. 

The normal disparity between the two sides of the 
chest is to be borne in mind with reference to di- 



140 AUSCULTATION IN DISEASE. 

minished or suppressed, as well as to increased vocal 
resonance ; otherwise, the relative feebleness of the 
resonance on the left side in health might be con- 
sidered to be morbid. The normally greater resonance 
on the right side renders it easier to determine a 
morbid diminution on this than on the left side. 

Diminished and Suppressed, Vocal Fremitus. — This 
tactile sensation, which is appreciable in auscultation, 
as a rule, is, on the one hand, increased, and, on the 
other hand, diminished or suppressed, under the same 
physical conditions which occasion corresponding 
modifications of the vocal resonance. Diminished 
or suppressed vocal fremitus, therefore, has the same 
diagnostic significance as diminished or suppressed 
vocal resonance. Usually the abnormal modifica- 
tions of resonance and fremitus go together, but 
either may be out of proportion to the other. The 
signs relating to fremitus thus corroborate those 
relating to resonance. The former may be marked 
when the latter admit of doubt. Diminished or 
suppressed fremitus is valuable in the diagnosis of 
pleurisy with effusion, empyema, hydrothorax, and 
pneumothorax. 

With regard to vocal fremitus, as to vocal reso- 
nance, it is essential to take cognizance of the nor- 
mal disparity between the two sides of the chest ; 
the greater relative fremitus, on the right side, as a 
rule, being no less marked than the relatively greater 
resonance on that side. 

Metallic Tinkling. — This sign has the same char- 
acters when it accompanies either the loud or whis- 
pered voice, or when it is heard with respiration, 
and, of course, it has the same significance. It may 



COUGHING OR TUSSIVE SIGNS. 141 

be more marked with acts of speaking than with 
the respiratory acts. 

Signs obtained by Acts of Coughing or Tussive Signs. 

Acts of coughing may be made subservient to 
auscultation of respiratory sounds in two ways : 
First, by the removal of temporary obstruction from 
the accumulation of mucus within bronchial tubes. 
If the respiratory murmur be diminished or sup- 
pressed over a portion or the whole of one side of 
the chest, sometimes an act of coughing effects clis- 
lodgment of a mass of mucus from either a primary 
bronchus or one of its subdivisions, and the normal 
murmur is at once restored. The dependence of the 
morbid sign upon a temporary obstruction is thus 
demonstrated. Second, by an act of coughing more 
air is expelled than by an ordinary expiration, and 
in the following inspiration the vesicles have a wider 
range of expansion, giving rise to a proportionately 
loud inspiratory sound ; hence, the characters of this 
sound are more pronounced and can be better studied. 
For these two objects it is often advisable to request 
the patient to cough with a certain degree of force. 

Acts of coughing, moreover, give rise to ausculta- 
tory signs which have their analogues in signs ob- 
tained by respiration and the voice. These tussive 
signs are of less value than the respiratory and vocal 
signs, and in most cases, owing to the latter being 
sufficient for diagnosis, they may be said to be super- 
fluous; nevertheless, they may be observed some- 
times with advantage. When the conditions are 
present which are represented by bronchial respira- 
tion, bronchophony and the bronchophonic whisper, 



142 AUSCULTATION IN DISEASE. 

sounds are obtained which correspond to these in 
their characters. The couffh is then said to be bron- 
chial. With the stethoscope applied over an empty 
cavity of some size, situated near the surface of the 
lung, the ear receives with acts of coughing a con- 
cussion or shock which is sometimes so forcible as 
to be painful. This corresponds to an intense vocal 
resonance. Limited to a circumscribed space, it is a 
highly significant cavernous sign. A low pitched 
blowing sound corresponds to the expiratory sound 
in the cavernous respiration and the cavernous 
whisper. An amphoric intonation may be heard 
with acts of coughing, which corresponds to ampho- 
ric respiration and amphoric voice. This sign is 
sometimes more marked with couffk than with the 
breathing and voice. Cavernous gurgling may also 
be obtained more distinctly with cough than with 
respiration. Finally, metallic tinkling not infre- 
quently accompanies acts of coughing. 



CHAPTER VI. 

THE PHYSICAL DIAGNOSIS OF DISEASES OF THE 
RESPIRATORY SYSTEM. 

•Affections of the larynx and trachea — Bronchitis seated in large bronchial 
tubes — Bronchitis seated in small bronchial tubes, or capillary bron- 
chitis — Collapse of pulmonary lobules — Lobular pneumonia — 
Asthma — Pulmonary or vesicular emphysema — Pleurisy, acute and 
chronic — Empyema — Hydrothorax — Pneumothorax — Pneumo-hydro- 
thorax — Acute lobar pneumonia — Circumscribed pneumonia — Embolic 
pneumonia — Hemorrhagic infarctus — Pulmonary apoplexy — Pulmo- 
nary gangrene — Pulmonary oedema — Carcinoma of lung — Tumor 
within the chest — Acute miliary tuberculosis — Phthisis— Fibroid 
phthisis — Interstitial pneumonia or cirrhosis of lung — Diaphragmatic 
hernia. 

In the preceding chapters the physical conditions 
incident to the morbid changes occurring in the 
affections of the respiratory system have been enu- 
merated ; and the physical signs obtained by percus- 
sion and auscultation representing these conditions 
have been considered, severally, as regards their 
distinctive characters and their significance. The 
object of this chapter is to group the physical con- 
ditions embraced in the different affections of the 
respiratory system respectively, together with the 
representative signs on which rests the physical 
diagnosis of each of the affections. The scope of 
this manual is limited to the physical diagnosis of 
these affections ; but the fact is not to be lost sight of 
that in practical medicine physical signs are not to be 
disassociated from symptoms and pathological laws. 
An exclusive reliance on physical signs would lead 



144 PHYSICAL DIAGNOSIS. 

to errors in diagnosis, although, doubtless, errors 
more important and more frequent necessarily occur 
when the practitioner ignores percussion and aus- 
cultation. The signs furnished by percussion and 
auscultation only have been thus far considered ; but 
in grouping these in this chapter, signs obtained by 
other methods of physical exploration will be em- 
braced in so far as they enter into the diagnosis of 
the different affections of the respiratory system. 
These different affections will be taken up separately 
with the exception of those seated in the larynx and 
trachea. With reference to physical signs the laryn- 
geal and tracheal affections may be considered 
collectively. 

Affections of the Larynx and Trachea. 

The physical signs referable to the chest in affec- 
tions of the larynx and trachea, denote more or less 
obstruction to the free passage of air through these 
sections of the air tubes. The obstruction in the 
different affections involves different pathological 
conditions. Spasm of the glottis is one of these 
conditions, constituting the affections known as 
laryngismus stridulus and spasmodic croup, occur- 
ring also as a pathological element in laryngitis, and 
sometimes in connection with aneurism, or a tumor 
of some kind, involving the recurrent laryngeal 
nerve. Another pathological condition is the oppo- 
site of this, namely, paralysis of the expanding 
muscles of the glottis, the vocal chords remaining 
flaccid, and approximating during inspiration. 
Other pathological conditions are, oedema of the 
glottis, swelling of the membrane at the glottis in 



AFFECTIONS OF LARYNX AND TRACHEA. 145 

laryngitis, and, in the adult, submucous infiltration, 
diphtheritic exudation, cicatrization of ulcers, mor- 
bid growths, and the presence of foreign bodies. 

In the affections involving the foregoing patho- 
logical conditions, percussion and auscultation are 
of use,jirst, by enabling the physician to exclude all 
affections within the chest. The absence of signs 
showing the existence of pulmonary diseases renders 
it certain that the symptoms denoting embarrass- 
ment of respiration are referable to the larynx or 
trachea. Second, by means of auscultation the 
amount of obstruction may be determined more 
accurately than by the subjective symptoms. The 
amount of obstruction is represented by a propor- 
tionate weakening of the vesicular murmur. This 
is more reliable as regards determining a dangerous 
amount of obstruction than the sense of the want of 
air or the suffering of the patient. The degree of 
diminution of the vesicular murmur is determinable 
with the more accuracy the better the auscultator is 
acquainted with the normal intensity, that is, the 
intensity prior to the occurrence of obstruction. 
With this knowledge, the weakening of the mur- 
mur is a correct criterion of the amount of obstruc- 
tion. In all the pathological conditions named, the 
respiratory murmur is more or less diminished in 
intensity on both sides of the chest; there are no 
signs obtained by percussion, nor do vocal resonance 
or fremitus offer anything distinctive. 

In cases of considerable or great obstruction, in- 
spection furnishes marked signs. The expansion of 
the chest on both sides is restricted, the lower part of 
the chest is contracted in the act of inspiration, and 
13 



146 PHYSICAL DIAGNOSIS. 

in this act the soft parts above the clavicles are 
depressed. The contrast between these abnormal 
movements and the normal thoracic movements of 
the patient is striking and distinctive. 

An important application of auscultation is the 
localization of a foreign body which has been inhaled. 
If the vesicular murmur on both sides be more or less 
weakened, the foreign body must be situated in either 
the larynx or the trachea. If, on the other hand, 
the vesicular murmur be weakened or suppressed on 
one side, and increased on the other side, the body 
is lodged in a primary bronchus. The importance 
of this application of auscultation before opening 
the trachea to remove a foreign body, is sufficiently 
obvious. The situation of a foreign body may be 
changed from one bronchus to the other by an act 
of coughing, even after an operation has been com- 
menced ; this is, of course, at once determinable by 
auscultation. 

Bronchitis Seated in Large Bronchial Tubes. 

In bronchitis, either acute or chronic, as it is ordi- 
narily presented in practice, the inflammation is 
seated in the large bronchial tubes, in many cases 
probably not extending beyond the primary bronchi. 
The physical conditions are, more or less swelling of 
the mucous membrane, this, however, not being suffi- 
cient to occasion any notable obstruction to the free 
passage of air, and the presence, in different cases, 
in greater or less quantity, of mucus, muco-purulent 
matter, pure pus, and serum. 

The physical diagnosis involves negative rather 
than positive points ; in other words, the affections 
from which bronchitis is to be differentiated are 



BRONCHITIS IN LARGE BKONCHIAL TUBES. 147 

excluded by the absence of their diagnostic signs. 
These affections are pneumonia, pleurisy, and 
phthisis. Each of these is characterized by the pre- 
sence of signs, the absence of which warrants its 
exclusion. In bronchitis there is no disparity be- 
tween the two sides of the chest in the resonance 
obtained by percussion, nor in vocal resonance, the 
bronchial whisper, and fremitus. The swelling of 
the bronchial mucous membrane may cause some 
diminution of the intensity of the vesicular murmur, 
but as the affection is bilateral, and the bronchial 
tubes on each side are affected equally, both in de- 
gree and extent, no appreciable disparity in this re- 
spect between the two sides is caused by this physical 
condition. Weakening or suppression of the mur- 
mur over an area greater or less, may be caused by 
bronchial obstruction from a plug of mucus. This 
obstruction is sometimes removed by an act of ex- 
pectoration, after which the murmur is found to have 
returned, or to have regained its normal intensity. 

The foregoing points, taken in connection with 
the history "and symptoms, suffice for the diagnosis. 
Signs due directly to the disease represent diminished 
calibre of the tubes at certain points from swelling 
of the membrane, adhesive mucus, and spasm of 
bronchial muscular fibres. These signs are the dry 
bronchial rales. They are rarely prominent, and are 
oftener absent than present, if the bronchitis be un- 
accompanied by asthma ; hence, they are of little 
value in the diagnosis. Other signs are the bubbling' 
sounds or the moist bronchial rales. In acute bron- 
chitis, these are oftener absent than present. They 
occur when there is an unusual quantity of liquid 



148 PHYSICAL DIAGNOSIS. 

morbid products, or their removal is with difficulty 
effected by expectoration in consequence of muscular 
debility or other causes. These rales are abundant 
and loud in proportion as the. liquid within the 
tubes is either muco-purulent, purulent, or serous in 
character. They are more or less coarse in propor- 
tion to the size of the tubes in which the bubblino* 
takes place. 

The diagnostic points, negativeand positive, which 
have been stated, are alike applicable to acute and 
chronic bronchitis, it being, of course, understood 
that the affection is primary, that is, not secondary 
to some other pulmonary disease. 

Bronchitis Seated in Small Bronchial Tubes. Capillary- 
Bronchitis. Collapse of Pulmonary Lobules. Lobular 
Pneumonia. 

Inflammation extending into the small tubes (capil- 
lary bronchitis) occasions in these the same physical 
conditions which are incident to bronchitis affecting 
tubes of large size, namely, swelling of the membrane, 
and the presence of liquid morbid products. The 
latter are not as easily removed by expectoration as 
when they are within large tubes, and, therefore, they 
are constantly present in greater or less quantity. 
These conditions in small tubes involve obstruction 
to the free passage of air to and from the air vesicles ; 
hence, the vast difference as regards the symptoms, 
the suffering, and the danger. The affection is bi- 
lateral, a fact greatly enhancing the gravity of the 
affection. An incidental physical condition is solidi- 
fication, generally in disseminated portions of lung, 
the latter varying in number and size. These por- 



CAPILLARY BRONCHITIS. 149 

tions of solidified lung denote either collapse of 
pulmonary lobules or lobular pneumonia, or both in 
conjunction. To this incidental affection, German 
writers apply the name " Catarrhal pneumonia." Of 
course, any discussion of pathological questions 
suggested by these names would be here out of place. 
With reference to diagnosis it is to be borne in mind 
that the solidified portions of lung in cases of bron- 
chitis seated in small tubes are especially situated in 
the lower lobes. Another incidental physical condi- 
tion is temporary dilatation of the air cells, or vesicu- 
lar emphysema, seated in the upper lobes. Both of 
these incidental conditions are bilateral, like the bron- 
chitis with wdiich they are connected. Collapse of 
pulmonary lobules, or lobular pneumonia, or both, and 
emphysema occur in only a certain proportion of the 
cases of bronchitis seated in small tubes. The signs, 
therefore, admit of a division into those which re- 
late, 1st, to the bronchitis, and, 2d, to these incidental 
affections. With reference to the diagnosis, the fact 
is to be borne in mind that bronchitis seated in small 
tubes occurs chiefly in children and the aged. 

The physical diagnosis of bronchitis seated in 
small tubes, rests on negative points, together with 
a positive sign which is uniformly present. This 
sign is the fine moist bronchial or subcrepitant rale, 
present on both sides and diffused over the chest. 
The bubbling sounds are to be distinguished from 
the fine dry crackling sounds or the crepitant rale, 
to the characters of which the former in some mea- 
sure approximate. 

The bronchitis gives rise neither to dulness on 
percussion, nor to any notable change in vocal reso- 

18* 



150 PHYSICAL DIAGNOSIS. 

nance, or fremitus. The respiratory murmur, if not 
obscured by rales, is weakened on both sides. Irre- 
spective of being drowned by rales, it may be sup- 
pressed by the amount of bronchial obstruction. 
These are the negative points in the diagnosis. In 
pulmonary oedema, fine moist bronchial rales are 
present on both sides, but in this affection there is 
notable dulness on percussion, and the affection 
occurs in certain pathological connections, namely, 
with mitral stenosis, and disease of the kidneys. 
Acute tuberculosis may present the moist bronchial 
rales with the negative points, which, in connection 
with symptoms, characterize bronchitis seated in 
the small tubes. The differentiation is to be based 
on differences pertaining to the history and duration, 
together with the age of the patient. 

The coexistence of the incidental affections, 
namely, collapse of pulmonary lobules, or lobular 
pneumonia and emphysema, occasions additional 
signs. If the solidified jDortions of lung be numerous, 
or considerable in size, there will be dulness on per- 
cussion in circumscribed situations on the posterior 
aspect of the chest. This will be found on both 
sides, but perhaps more marked on one side. Bron- 
cho-vesicular or the bronchial respiration may be 
present, together with the vocal signs of solidifica- 
tion, namely, either increased vocal resonance, or 
bronchophony, and increased vocal fremitus. The 
pitch of the moist rales produced within solidified 
portions of lung will be high in pitch, whereas, if 
solidification do not exist, these rales are compara- 
tively low in pitch. The existence of solidification 
at any point may be determined by the pitch of the 



ASTHMA. 151 

rales, as well as by the foregoing respiratory and 
vocal signs. 

On the anterior aspect of the chest in the upper 
and middle regions, on both sides, the resonance on 
percussion is vesiculotympanitic, the respiratory 
murmur weakened or suppressed, and the rhythm 
altered — in short, the combination of signs which 
will be stated under the head of emphysema. 

In the cases in which the bronchitis occasions 
great obstruction in the small tubes, and, still more, 
if collapse of lobules, or lobular pneumonia and 
emphysema occur, important signs are obtained by 
inspection. The anterior portion of the chest re- 
mains expanded, and retraction of the lower part of 
the chest takes place in the acts of inspiration. 

Asthma. 

The pathologico-physical condition in a paroxysm 
of asthma, is obstruction in the small bronchial 
tubes attributable to spasm of the bronchial mus- 
cular fibres. "With this condition is associated a 
temporary vesicular emphysema, which exists often 
as a persistent affection in persons who are subject 
to asthma. If the emphysematous condition already 
exist, it is increased during the paroxysm of asthma. 
Bronchitis generally coexists either as a transient or 
a chronic affection. In an asthmatic paroxysm, 
therefore, there are present the signs which are 
proper to asthma, together with those of emphysema, 
and associated bronchitis may also occasion addi- 
tional signs. 

The physical diagnosis of asthma, like that of 
bronchitis seated in small tubes, is based on negative 



152 PHYSICAL DIAGNOSIS. 

points taken in connection with a sign which is 
invariably present, namely, dry bronchial rales. 
These rales are more or less intense, and they are 
diffused over the entire chest. They are generally 
heard at a distance. The sibilant and sonorous 
varieties are mingled, and they are constantly 
changing as regards the character of the sounds. 

The negative points are the same as in capillary 
bronchitis, namely, absence of dulness on percussion, 
vocal resonance and fremitus also being; unaltered. 
Asthma and bronchitis seated in small tubes agree 
in the fact that obstruction is the important physical 
condition. Pathologically they differ essentially in 
the obstruction being due in the latter affection to 
bronchial inflammation, and in the former to spasm. 
The two affections differ in the signs representing 
these different conditions, fine moist bronchial rales 
existing in one, and loud diffused dry bronchial rales 
existing in the other. 

Taking the difference as regards the positive 
physical signs in connection with the history and 
symptoms, the differentiation of the two affections 
may be made without difficulty. 

The signs which relate to the associated emphyse- 
matous condition, are those which are diagnostic of 
this condition, existing irrespective of asthma ; and 
the physical diagnosis of emphysema will be next 
considered. Coexisting bronchitis may give rise to 
moist bronchial rales more or less coarse. These are, 
however, often wanting, and they are rarely marked 
during paroxysms of asthma. When present in 
this pathological connection, they are low in pitch, 
denoting the absence of solidification of lung. 



PULMONAKY EMPHYSEMA. 153 

Pulmonary or Vesicular Emphysema. 

This affection, as a rule, is seated exclusively or 
chiefly in the upper lobes. When it is lobar, in con- 
tradistinction from lobular emphysema (in the latter 
variety the condition existing in comparatively a few 
disseminated or isolated portions of lung), increase 
in volume of the affected lobes is an important 
physical condition standing in relation to certain 
signs. Diminished range of expansion with acts of 
inspiration is another physical condition ; the affected 
lobes are in a permanent state of expansion approxi- 
mating to that at the end of the inspiratory act. It 
follows from these conditions that the amount of air 
is in excess of the normal proportion to the solids 
and liquids in the affected lobes. Both lungs are 
affected, that is, the affection is bilateral. In the 
great majority of cases chronic bronchitis coexists, 
and patients affected with emphysema are often, but 
by no means invariably, subject to paroxysms of 
asthma. 'Not infrequently an asthmatic element, 
with or without pronounced paroxysms of asthma, 
exists much of the time in connection with emphy- 
sema. The emphysematous condition, as a rule, with 
few exceptions, is greater in the upper lobe of the 
left than of the right lung. A rare condition, which 
is generally included under the name emphysema, 
differs materially from the ordinary form of this 
affection. This condition is that also known as 
senile atrophy of the lungs. The volume of the 
lungs is not increased in this variety of emphysema, 
the proportion of air over the solids is, however, in 
excess, owing to the diminution of the latter from 
atrophy. 



154 PHYSICAL DIAGNOSIS. 

The diagnostic evidence obtained by percussion is 
quite distinctive of ordinary lobar emphysema. The 
resonance over the upper and middle regions of the 
chest on both sides is vesiculotympanitic, that is, 
the intensity of the resonance is abnormally increased, 
the quality is a combination of the vesicular and 
tympanitic, and the pitch is more or less raised. 
Owing to the fact that the emphysema is greater on 
the left than on the right side, the vesiculo-tympa- 
nitic resonance is more marked on the left side. The 
difference in intensity between the two sides may 
lead to the error of regarding the resonance on the 
right side as dulness. The error is avoided by 
attention to the pitch and the quality of the reso- 
nance. If dulness existed on the right side, the 
pitch of the sound should be higher on that side ; 
on the other hand, if the difference in intensity be 
due to the greater amount of emphysema on the 
left side, the pitch is higher on that side, and the 
quality vesiculo-tympanitic. The attention of the 
student is particularly called to the foregoing points 
of distinction. Assuming that a vesiculo-tympanitic 
resonance exists anteriorly on both sides, and that it 
is marked on the left as contrasted with the right 
side, how is the existence of 'this sign on the right 
side to be determined ? The answer is, the resonance 
over the upper is to be compared with that over the 
low^er lobe of the right rung. Percussing first over 
the upper lobe of the right lung, and second over the 
lower lobe of this lung, that is, posteriorly, below 
the scapula, or in the infra-axillary region, the 
vesiculo-tympanitic resonance over the upper lobe is 
rendered manifest. In a series of patients affected 



PULMONAilY EMPHYSEMA. 155 

with emphysema, the uniformity of the results of 
percussion is very striking; anteriorly, over the 
left side, the resonance is vesiculo-tympanitic as 
compared with the resonance on the right side, and 
the resonance is shown to be vesiculo-tympanitic on 
the right side anteriorly as compared with the reso- 
nance posteriorly below the scapula. 

As regards the abnormal modifications of* the 
respiratory murmur in emphysema, there is, first, 
weakened or, it may be, suppressed respiratory 
sounds without notable change in pitch or quality. 
Diminished intensity of the murmur exists over the 
upper lobes on both sides, as compared with the 
murmur over the lower lobes; and in most cases 
the greater diminution or the suppression is on the 
left rather than on the right side. Exceptions to 
the latter statement may be caused by obstruction 
of the bronchial tubes on the right and not on the 
left side by an accumulation of mucus, and, in rare 
instances, by the fact that the emphysema is greater 
on the right side. Second, modifications in rhythm 
are not infrequent. These consist in a shortened 
(deferred) inspiratory, and a prolonged expiratory 
sound. In some instances an inspiratory sound is 
wanting, and an expiratory sound is alone heard. 
The prolonged expiratory sound in emphysema is 
always low in pitch and blowing or non-tubular in 
quality, in these respects differing from the prolonged 
expiration which denotes solidification of lung, the 
latter being high in pitch and tubular in quality. 
These essential points of difference I claim to have 
been the first to point out distinctly. 

The foregoing signs obtained by percussion and 



156 PHYSICAL DIAGNOSIS. 

auscultation are those which are in a positive sense 
diagnostic of emphysema. Associated with these are 
certain important negative points, as follows: vocal 
resonance, vocal fremitus, and bronchial whisper are 
not notably altered. These negative points suffice 
to exclude other affections than emphysema. 

Signs obtained by inspection are quite distinctive 
of this affection. Emphysema, existing in a marked 
degree, causes a characteristic deformity of the chest ; 
the anterior surface is bulging, giving to the chest 
an abnormally rounded, bow-windowed, or barrel- 
shaped appearance, the lower part appearing to be 
contracted. This deformity occurs when the emphy- 
sema has been developed in early life. The move- 
ments of the chest in inspiration are characteristic. 
In tranquil breathing there is but little movement 
of the upper and middle anterior regions; but in 
forced breathing the sternum and ribs move together 
as if they were one solid piece. The lower portion 
of the chest and the epigastrium are retracted in 
inspiration ; the costal angle is diminished, the ribs 
and cartilages connected with the sternum being 
sometimes on a line ; the soft parts above the clavicle 
and sternum are often notably depressed with inspi- 
ration. Owing to depression of the heart downward 
and inward, the cardiac impulses are seen and felt in 
the epigastrium. Percussion and vocal resonance, 
at the same time, show the superficial cardiac region 
to be diminished or lost, the upper lobe of the left 
lung covering this space. There may be more or 
less anterior curvature of the spine, and the lower 
portions of the scapulas may project, so that some- 
times the plane of these bones is almost horizontal. 



PULMONARY EMPHYSEMA. 157 

These striking appearances characterize cases in 
which emphysema exists in a marked degree, and 
especially when the affection dates from early life. 
They are less marked or wanting if the emphysema 
be moderate in degree, and it have taken place in 
middle-aged persons or those advanced in years. 

In the variety of emphysema distinguished as 
senile, or senile atrophy of the lungs, in which there 
is coalescence of air vesicles, from destruction of the 
cell walls, without increased volume of the affected 
lobes, the diagnosis is to be based on the vesiculo- 
tympanitic resonance on percussion, weakened respi- 
ratory murmur, with, perhaps, the alterations in 
rhythm, sinking of the soft parts above the clavicles, 
and the negative points, exclusive of deformity of 
the chest, which have been described. 

Emphysema can hardly be confounded with any 
other affection than phthisis. The differentiation 
between these two affections is sufficiently easy, if 
the diagnostic points, positive and negative, of the 
former, be appreciated. Phthisis occurring in a 
patient affected with emphysema, makes a somewhat 
difficult problem in diagnosis, but, fortunately for 
the diagnostician, a patient with emphysema very 
rarely becomes phthisical. 

Owing to the frequency with which an asthmatic 
element enters into the clinical history of emphysema, 
the dry bronchial (sibilant and sonorous) rales are 
often present, even when paroxysms of asthma do 
not occur. 



14 



158 PHYSICAL DIAGNOSIS. 

Pleurisy, Acute and Chronic. Empyema. Hydrothorax. 

In the first stage of acute pleurisy, that is, prior 
to the effusion of liquid, the physical conditions are, 
the presence of more or less recently exuded, soft, 
and glutinous lymph upon the pleural surfaces, which 
are now in contact, and restrained movements of 
respiration on the affected side in consequence of the 
pain which they occasion. In the second stage, 
serous liquid accumulates within the pleural cavity, 
the quantity varying in different cases, sometimes, 
although rarely, filling the chest on the affected side. 
In proportion to the quantity of liquid, the space 
over which the pleural surfaces are in contact is re- 
stricted, the movements of these surfaces over each 
other are limited, and the lung is condensed. In the 
third stage, the quantity of liquid decreases, the 
space over which the pleural surfaces are in contact 
increases, and the compressed lung is more or less 
expanded. The lymph upon the pleural surfaces 
becomes more dense and adherent. The surfaces may 
become agglutinated by the intervening lymph. 
Finally, in convalescence, permanent adhesions re- 
sult from the production or growth of areolar 
tissue. 

In subacute and chronic pleurisy, there is the 
same series of physical conditions, the points of 
difference being, as a rule, a less amount of exuda- 
tion, and a greater amount of effused liquid. The 
quantity of liquid in chronic pleurisy is often suffi- 
cient to compress the lung into a small solid mass, 
situated at the upper and posterior part of the chest, 
and to dilate the affected side. The heart is often 



ACUTE AND CHRONIC. 159 

removed from its normal situation. If the pleurisy 
be on the left side, the heart may he pushed laterally 
beyond the right margin of the sternum ; if the 
pleurisy be on the right side, the heart is pushed 
laterally to the left of its normal situation. 

In empyema the accumulation of pus is apt to be 
still greater than that of serous effusion in simple 
chronic pleurisy, causing, of course, greater dilatation 
of the chest, and more displacement of the heart. 

In these varieties of pleurisy, the affection, with 
rare exceptions, is unilateral. 

In hydrothorax the conditions differ, first, as re- 
gards the absence of the exudation of lymph ; second, 
the affection is bilateral, the effusion of liquid taking 
place in both pleural cavities; and third, although 
the quantity of liquid may be considerably greater 
on one side, the accumulation very rarely, if ever, 
is sufficient to cause much dilatation of the chest on 
that side, with complete condensation of the lung, 
and notable displacement of the heart. 

The signs in the first stage of acute pleurisy are 
relative feebleness of the respiratory murmur on the 
affected side, from the restrained respiratory move- 
ments on that side, and a rubbing friction sound. 
The former is not distinctive of pleurisy, being pre- 
sent when the respiratory movements on one side are 
restrained by pain in intercostal neuralgia and pleuro- 
dynia. A friction sound is not always obtained. 
In the absence of this sound, the physical diagnosis 
cannot be made with positiveness prior to the effu- 
sion of liquid. Assuming that the general and local 
symptoms point to an acute inflammatory affection, 
the differential diagnosis relates to pleurisy and 



160 PHYSICAL DIAGNOSIS. 

pneumonia. A pleural friction sound may be pre- 
sent in the latter as well as the former of these two 
affections. The pathognomonic sign of pneumonia, 
the crepitant rale, being wanting, the differentiation, 
in this stage, must rest on diagnostic points pertain- 
ing to the symptoms. 

In the second stage of acute pleurisy, the diag- 
nostic signs are those which denote the presence of 
liquid within the pleural cavity. These signs are 
simple and distinctive. There is either clulness or 
flatness on percussion at the base of the chest, 
extending upward a distance proportionate to the 
quantity of liquid. If the trunk be in a vertical 
position, that is, the patient sitting or standing, the 
line of demarcation between the clulness or flatness 
and pulmonary resonance, is a horizontal line, on 
either the anterior, lateral, or posterior aspect of the 
chest. This line denotes the level of the liquid, and 
it is easily obtained by percussion. It is as easily 
determined by auscultating the vocal resonance, this 
either abruptly ceasing or being notably diminished 
at the level of the liquid. Having ascertained the 
horizontal line forming the upper boundary of clul- 
ness or flatness on the anterior aspect of the chest, 
the patient sitting or standing, if the position be 
changed to recumbency on the back, and the pulmo- 
nary resonance be found then to extend more or less 
below this line, this fact is demonstrative proof of 
the presence of liquid. Proof in this way is ob- 
tained in a large majority of cases, the exceptional 
cases being those in which the pleural surfaces are 
united, either by agglutination or permanent adhe- 
sions, above the level of the liquid. The resonance 



PLEUEISY, ACUTE AND CHEONIC. 161 

on percussion over the lung above the level of the 
liquid is generally vesiculotympanitic — the intensity 
increased, the pitch raised, the vesicular and tym- 
panitic quality combined. Sometimes there is so 
little vesicular quality in this vesiculotympanitic 
resonance, that it may seem to be purely tympanitic, 
and is suggestive of pneumothorax. Associated 
signs will always prevent this error of observation. 
Yocal resonance and fremitus are either notably 
lessened or suppressed over the portion of the chest 
situated below the level of the liquid. The respira- 
tory sound below the level of the liquid is suppressed. 
If any be heard, it is transmitted either from the 
lung above the liquid, or, laterally, from the lung on 
the other side of the chest. Above the liquid the 
respiratory sound, as a rule, is weakened. If the 
amount of liquid be sufficient to produce much con- 
densation of lung, the respiratory sound is broncho- 
vesicular. Sometimes, owing to the pleural surfaces 
above being adherent, a strip of lung at the level of 
the liquid is sufficiently condensed by compression 
to give a bronchial respiration. Under these circum- 
stances, there w r ill be either bronchophony or the 
modification of that sign known as segophony. If 
the lung be not sufficiently compressed for the pro- 
duction of these signs of solidification, the vocal reso- 
nance is simply more or less increased. The fremitus 
is usually increased above the liquid. Over the un- 
affected side the respiratory murmur is increased in 
intensity. 

The foregoing signs are present when the pleural 
cavity is partially filled ; a quarter, a half, or two- 
thirds of the thoracic space being occupied by 

14* 



162 PHYSICAL DIAGNOSIS. 

liquid. The signs present when the cavity is com- 
pletely filled, will be presently stated in connection 
with chronic pleurisy. 

The signs which have been stated show not only 
the presence of liquid, but its quantity. By means 
of these signs are readily ascertained the progressive 
increase or decrease in the quantity of liquid, and 
its disappearance. After the liquid has disappeared, 
often notable dulness on percussion remains for 
some time, showing the presence of lymph not yet 
absorbed. During the decrease of the liquid, and 
after its disappearance, a friction murmur is often 
perceived. This murmur is now apt to be rough — 
a rasping, grating, or creaking sound. It may be 
loud enough to be heard by the patient, and by 
others at a distance from the chest. It continues 
sometimes for a considerable period. 

The physical diagnosis in cases of chronic pleurisy, 
when the liquid occupies a portion only of the tho- 
racic space, rests, of course, on precisely the same 
signs as in cases of acute pleurisy. If, however, the 
chest on the affected side be filled and dilated, certain 
of the signs which have been stated are wanting, 
and others are added. The affected side is every- 
where flat on percussion. Flatness on percussion 
over the whole of one side, the affection being 
chronic, denotes, as a rule, with rare exceptions, 
either chronic simple pleurisy or empyema. Respi- 
ratory sound is wanting except at the summit over 
or near the compressed lung, where it is bronchial. 
Some cases offer an important exception to this rule, 
namely, the bronchial respiration is diffused over 
the greater part, or even the whole, of the affected 



PLEURISY, ACUTE AND CHRONIC. 163 

side. The student should bear in mind this fact; 
otherwise, the diffusion of the bronchial respiration 
may lead to the suspicion that the flatness on per- 
cussion denotes solidification of lung, and not the 
presence of liquid. Other signs, however, should 
always correct this error. Vocal resonance and 
fremitus are either suppressed or notably diminished 
over the whole of the affected side. Generally, even 
when the chest is not dilated, the intercostal depres- 
sions are lessened or abolished. If the walls of the 
chest be thinly covered with integument, the two 
sides present a marked contrast in this respect. This 
is seen especially at the middle and lower regions of 
the chest anteriorly and laterally. It is especially 
marked at the end of the inspiratory act. If the 
affected side be dilated, this is apparent on inspec- 
tion, and may be determined accurately by semi- 
circular or diametric mensuration, callipers being 
required for the latter. The respiratory movements 
on the affected side are diminished or annulled, and 
they are increased on the healthy side, the two sides 
affording a marked contrast in this regard. If the 
pleurisy be on the left side, the impulses of the heart 
are not infrequently felt on the right of the sternum. 
If the impulses cannot be felt, auscultation shows 
the maximum of the intensity of the heart-sounds 
to be more or less removed to the right. If the 
pleurisy be on the right side, the impulses or sounds 
of the heart denote more or less displacement late- 
rally to the left. The intensity of the respiratory 
murmur on the unaffected side is notably increased. 
In cases of empyema the same signs are present 
as in chronic pleurisy. The character of the liquid 



164 PHYSICAL DIAGNOSIS. 

does not alter appreciably any of the signs which 
have been stated. Dilatation of the affected side of 
the chest is more apt to occur, and to be more marked 
than in simple pleurisy. The differential diagnosis 
between these two varieties of pleurisy is to be made 
with positiveness by the introduction of a small 
trochar and obtaining enough of the liquid to ascer- 
tain its character. 

When the left pleural cavity is filled with pus, 
the movements of the heart sometimes give to the 
affected side of the chest an impulse perceived by the 
eye and touch ; hence, the term pulsating empyema. 
After a spontaneous perforation of the chest followed 
by a circumscribed purulent collection beneath the 
integument communicating with the pus within the 
pleural cavity, the tumor thus formed sometimes has 
a strong pulsation which is synchronous with the 
ventricular systole, and may give rise to the suspicion 
of aneurism. 

In cases of hydrothorax the signs denote partial 
filling of the chest on both sides. The affection is 
bilateral. Generally the quantity of liquid in the 
two sides is not equal, and there is often a notable 
disparity in this respect. Friction sounds are never 
present. Variation of the level of the liquid with 
change of the position of the patient from the verti- 
cal to the horizontal, is nearly always determinable. 
Hydrothorax, meaning by this term a purely dropsi- 
cal affection, is to be differentiated from double 
pleurisy with effusion. The history and symptoms, 
taken in connection with the signs, suffice for this 
discrimination. 



PNEUMO-HYDROTHORAX. 165 

Pneumothorax. Pneumo-hydrothorax. 

In the extremely rare cases of pneumothorax, that 
is, as distinguished from pneumo-hydrothorax, the 
physical conditions are : the presence of air partially 
or completely occupying the thoracic space, and con- 
densation of lung in proportion to the space occupied 
by air. 

TKe diagnostic signs are, a purely tympanitic reso- 
nance over a portion or the whole of the affected 
side of the chest ; suppression of the vesicular mur- 
mur over a space corresponding to that in which 
tympanitic resonance is obtained, with notable dimi- 
nution or suppression of vocal resonance and fremitus. 
Over the compressed lung, if the condensation amount 
to complete or considerable solidification, there will 
be bronchial respiration and bronchophony ; if the 
solidification be not complete nor considerable, there 
will be broncho-vesicular respiration with increased 
vocal resonance and fremitus. The accumulation of 
air may be sufficient to dilate the affected side, and 
to restrain or annul the respiratory movements on 
this side. The appearances on inspection are then 
precisely the same as in the cases of chronic pleurisy 
and empyema in which the affected side is dilated 
from the presence of liquid. Pneumothorax is, how- 
ever, at once differentiated by the tympanitic reso- 
nance on percussion. If one side of the chest be more 
or less dilated, and the resonance over the side be 
purely tympanitic, the thoracic space must be filled, 
not with liquid, but with air. The intensity of the 
respiratory murmur on the healthy side is increased. 

In the great majority of cases in which the pleural 



166 PHYSICAL DIAGNOSIS, 

cavity contains air, there is also present more or less 
liquid, which may be serous or purulent. The affec- 
tion is then known as pneumo-hydrothorax. The 
physical conditions are the same as in pneumothorax, 
with the exception of the presence of liquid. The 
relative proportions of liquid and air in different 
cases are variable, and, also, in the same case at dif- 
ferent periods. 

The physical diagnosis of pneumo-hydrothorax, 
as distinguished from pneumothorax, embraces the 
signs of liquid, in addition to those of air, within 
the pleural cavity. If the quantity of liquid be large 
or considerable, percussion at the base of the chest 
gives flatness extending upward more or less, and 
tympanitic resonance above, the patient either sitting 
or standing. The upper limit of flatness when the 
body is vertical is bounded by a horizontal line on 
the anterior, or lateral, or posterior aspect of the 
chest. A change from the vertical to the horizontal 
position invariably causes variation of the upper limit 
of the flatness, inasmuch as the liquid and air change 
their relative situations without an exception. The 
quantity of liquid is determined approximately by 
ascertaining the space over which the flatness on 
percussion extends. The line which divides the flat- 
ness and the tympanitic resonance does not accurately 
denote the level of the liquid, because tympanitic 
resonance is transmitted a certain distance below 
this level ; hence, it is always to be assumed that 
the level of the liquid is somewhat higher than the 
upper boundary of the flatness. 

In both pneumothorax and pneumo-hydrothorax 
a group of auscultatory signs are often found which 



ACUTE LOBAR PNEUMONIA. 167 

are "highly diagnostic, indeed almost pathognomonic. 
These signs are amphoric respiration, amphoric voice 
or echo, and metallic tinkling. The amphoric and 
the tinkling sounds may he present, either without 
the other, hut they are not infrequently associated. 
Neither are present in every case, and they are not 
present in the same case at all times; their ahsence, 
therefore, by no means excludes the affections, and 
they are not essential to the diagnosis. When pre- 
sent, they denote either air or air and liquid in the 
pleural cavity with perforation of lung, or a large 
phthisical cavity. Their occurrence in the latter is 
extremely rare, and, whenever they are associated 
with other signs already stated, their diagnostic im- 
port is demonstrative. 

Pneumo-hydrothorax may almost invariably be 
diagnosticated instantly by the presence of a succus- 
sion sound. Whenever distinct splashing is pro- 
duced by percussion and referable to the chest, that 
is, not produced within the stomach, it is demon- 
strative of the presence of air and liquid within the 
pleural cavity. 

Acute Lobar Pneumonia. 

In the first stage of this disease, there is an ab- 
normal accumulation of blood within the vessels of 
the affected lobe (active congestion or hyperemia), 
with some glutinous exudation within the air vesi- 
cles and bronchioles. Generally some exuded lymph 
is upon the pleural surface, this being due to circum- 
scribed dry pleurisy. In most cases there is also cir- 
cumscribed bronchitis, which is limited to the tubes 
within the affected lobe. In the second stage, there 



168 PHYSICAL DIAGNOSIS. 

is solidification, due to fibrinous exudation within 
the air vesicles. The solidification, at first limited, 
extends either rapidly or slowly, as a rule, over the 
whole lobe. Exceptionally, more or less liquid effu- 
sion into the pleural cavity takes place (pleuro-pneu- 
monia), the pleurisy then extending beyond the limits 
of the affected lobe. In this stage the pneumonia 
may involve either another lobe of the lung prima- 
rily affected, or a lobe of the opposite lung ; and 
sometimes the affection, by successive invasions, ex- 
tends over the whole of one lung, together with a 
lobe of the opposite lung. The pneumonia, in these 
secondary invasions, is usually accompanied by pleu- 
risy and bronchitis. In the stage of resolution, the 
solidification of the affected lobe, or lobes, decreases, 
sometimes rapidly and sometimes slowly, until the 
normal condition is restored. If resolution do not 
take place, and the affection pass into the stage of 
purulent infiltration, the air vesicles and bronchial 
tubes contain a puruloid liquid in greater or less 
quantity. Exceptionally pus is collected in a cavity, 
or in cavities, constituting pulmonary abscess. 

The physical diagnosis of acute lobar pneumonia 
in the first stage, must be based on the presence of 
the crepitant rale, with moderate or slight dulness 
on percussion over the affected lobe. There is some- 
times in this stage a pleuritic rubbing sound over 
the affected lobe. The crepitant rale is not always 
present, and, hence, the affection cannot be excluded 
by the absence of this sign. When present, taken 
in connection with the symptoms, this sign is pa- 
thognomonic of the affection. It is important not to 
mistake for this sign fine bubbling or the subcrepi- 



ACUTE LOBAR PNEUMONIA. 169 

taut rale. When the crepitant rale is wanting, a 
positive physical diagnosis must he deferred until 
more or less of the affected lohe becomes solidified, 
that is, when the affection passes into the second 
sta^e. 

The diagnosis in the second stage is to he "based on 
the signs of solidification furnished hy auscultation 
and percussion. The auscultatory signs are the 
broncho-vesicular, followed hy the bronchial, respi- 
ration ; increased vocal resonance, followed by bron- 
chophony, and increased bronchial whisper, followed 
by whispering bronchophony. The signs of solidi- 
fication are manifest at first within a circumscribed 
space, situated over either the upper, the lower, or 
the middle portion of the affected lobe ; and either 
rapidly or slowly the signs extend, in most cases, 
over the entire lobe. The crepitant rale, if it have 
been present in the first, generally disappears in the 
second stage. Sometimes, however, it is not entirely 
lost in this stage. The broncho-vesicular respiration, 
increased vocal resonance, and increased bronchial 
whisper are present when the solidification is slight or 
moderate ; the bronchial respiration, bronchophony, 
and bronchophonic whisper take their place when 
the solidification becomes considerable or complete. 
The latter signs, as a rule, speedily follow, inasmuch 
as the solidification in most cases quickly becomes 
complete or considerable. The foregoing three 
signs, denoting considerable or complete solidifica- 
tion, are usually present. Bronchial respiration, 
however, is sometimes present without broncho- 
phony, and vice versa. Either, present alone, suffices 
to show the existence and the extent of the solidifi- 
15 



170 PHYSICAL DIAGNOSIS. 

cation. Moist bronchial or bubbling rales are 
sometimes, but rarely, heard over the affected lobe. 

There is notable dulness on percussion in the 
second stage. The dulness may approximate, and 
even amount to flatness. If a single lobe be affected, 
the dulness, or flatness, extends over a space corres- 
ponding to that occupied by the lobe or the portion 
of it which is solidified. In the antero-lateral aspects 
of the chest, the dividing line between the solidified 
and the healthy lobe is readily ascertained by per- 
cussion, and this line is coincident with the inter- 
lobar fissure. It sometimes happens that the upper 
and the lower lobe of the right lung are affected, 
the middle lobe not becoming involved. The space 
corresponding to the middle lobe may then form an 
island of resonance surrounded by notable dulness 
on percussion. 

Whenever one lobe of a lung is affected, the reso- 
nance over the unaffected part of the same lung is 
abnormally increased, the pitch is raised, and the 
quality is vesiculotympanitic ; vesiculotympanitic 
resonance, in other words, is produced. This renders 
more marked the contrast between dulness over the 
solidified, and resonance over the healthy, lobe. 

Over a portion of an upper lobe in the second 
stage, instead of notable dulness or flatness, there 
may be marked tympanitic resonance. This reso- 
nance proceeds from air within the trachea, and the 
bronchi exterior to the lungs, the lung-substance 
being completely solidified ; it is chiefly or especially 
marked over the site of these air tubes. In some 
cases the tympanitic resonance has the cracked-metal 
or the amphoric intonation. These signs, per se y 



ACUTE LOBAR PNEUMONIA. 171 

might suggest either pneumothorax or phthisical 
cavities ; the associated respiratory and vocal signs, 
however, show only solidification of lung. In cases 
of pneumonia affecting the left lung, a tympanitic 
resonance is not infrequently propagated from the 
stomach more or less upward over the affected side 
of the chest. This may be readily traced to the 
stomach. On the right side, a tympanitic resonance 
is sometimes propagated, a certain distance upward, 
from the transverse colon. 

The commencement of the stage of resolution is 
denoted by a broncho-vesicular respiration. The 
first change observed is the presence of a little vesicu- 
lar quality in the inspiratory sound. When this is 
observed, the respiration is no longer bronchial, but 
has become broncho- vesicular, although the pitch is 
still high, and the expiration is prolonged, high, 
tubular. This slight change shows that air begins 
to enter the pulmonary vesicles. As resolution goes 
on, more and more of the vesicular takes the place 
of the tubular quality in the inspiratory sound, and 
the pitch is lowered in proportion; the expiratory 
sound becomes proportionately less and less pro- 
longed, its pitch lowered, its quality less tubular, 
until, at length, the normal characters of the respi- 
ratory murmur are regained. Resolution is then 
complete. 

While the broncho-vesicular respiration is under- 
going the modifications just stated, the vocal sounds 
have corresponding changes. Bronchophony per- 
sists for some time after the respiration has become 
broncho-vesicular, and then disappears, increased 
vocal resonance generally taking its place, and per- 



172 PHYSICAL DIAGNOSIS. 

sisting until resolution is completed. The bronchial 
whisper loses its broncliophoiric characters, and is 
simply increased until its normal characters are re- 
gained. "While the solidification is complete, the 
vocal fremitus may, or may not, be increased. It is 
sometimes diminished. When, however, resolution 
has so far progressed that bronchophony is lost, the 
fremitus is usually greater than in health, and so 
continues, but progressively lessening until the 
solidification entirely disappears. 

During the progress of resolution, the dulness on 
percussion diminishes in proportion as air enters the 
air vesicles. If tympanitic resonance have been pre- 
sent over the upper lobe, this gives place to a vesicular 
resonance. Some dulness, however, remains after 
the completion of resolution, and persists until the 
exuded lymph on the pleural surface is absorbed. 
The amount of dulness remaining when the respira- 
tory and vocal signs denote resolution, is propor- 
tionate to the quantity of exudation incident to the 
associated pleurisy. 

In this stage the crepitant rale not infrequently 
returns, if it have entirely disappeared during the 
second stage, and if it have persisted, it is more 
marked and diffused. It is now known as the re- 
turning crepitant rale. More frequently the rale in 
this stage is a fine bubbling or the subcrepitant. 
Both rales are not infrequently associated ; and, from 
the distinctive characters of each, they are readily 
distinguished. Moist rales more or less fine or coarse 
are not infrequent. 

If the affection pass into the stage of purulent 
infiltration, the respiratory sounds are feeble or sup- 



CIRCUMSCRIBED PNEUMONIA. 173 

pressed, having, if present, more or less of the bron- 
chial characters. Bubbling bronchial rales, coarse 
and fine, are abundant. Weak bronchophony may 
persist, or the vocal resonance may be diminished. 
Fremitus may, or may not, be increased. Notable 
dulness or flatness on percussion remains. 

If the pneumonia result in pulmonic abscess, there 
will be notable dulness or flatness on percussion 
within a circumscribed space, together with absence 
of respiratory murmur, and diminished or sup- 
pressed vocal resonance. These signs warrant a 
probable diagnosis which is corroborated by the 
sudden expectoration of pus in a considerable quan- 
tity. The signs just stated may then be followed by 
those denoting a cavity, namely, cavernous respira- 
tion and whisper, with intense vocal resonance. 

Circumscribed Pneumonia. Embolic Pneumonia. Hemor- 
rhagic Infarctus or Pulmonary Apoplexy. 

The form of pneumonia known as lobular pneu- 
monia, occurring chiefly in children, has been con- 
sidered (vide Bronchitis seated in small-sized tubes). 
Whenever circumscribed, as a rule, pneumonia is 
secondary to some other pulmonary affection. Cir- 
cumscribed pneumonia, having the anatomical 
characters of acute lobar pneumonia, that is, giving 
rise to an intra-vesicular exudation which may 
disappear readily by resolution or absorption, is not 
infrequent in cases of phthisis. The signs are those 
which represent solidification of lung within an 
area more or less circumscribed ; but the differentia- 
tion from the solidification proper to phthisis (tuber- 
culous pneumonia), can only be made with positive- 

15* 



174 PHYSICAL DIAGNOSIS. 

ness after the signs have showed that the solidification 
has notably diminished or disappeared. 

In embolic pneumonia, followed by what has been 
known as metastatic abscesses, there may be dulness 
on percussion, with feeble bronchial or broncho- 
vesicular respiration, or suppression of respiratory 
sound, weak bronchophony or increase of vocal 
resonance, within a circumscribed space, or spaces, 
generally on the posterior aspect of the chest, and 
oftenest on the right side. These signs, taken in 
connection with the symptoms and pathological 
conditions which are consistent with the supposition 
of infectious emboli received into the right side of 
the heart, namely, when the pulmonary symptoms 
follow puerperal disease, ulcers, wounds, or injuries, 
render the diagnosis quite positive. If, however, the 
pulmonary affection consist of small disseminated 
nodules, the foregoing signs will not be present. 
The diagnosis then must be based on the history and 
synrptoms, taken in connection -with the exclusion 
of other pulmonary affections by the absence of 
signs which should be present if they existed. Bub- 
bling rales at different situations may indicate the 
probable sites of the nodules. There may be pleu- 
ritic friction sounds. The signs may show, as a 
complication, pleurisy with effusion. 

Extravasation of blood (pneumorrhagia), if it be 
in small spaces, gives rise to no definite physical 
signs. If, however, extravasation extend over a con- 
siderable space, there will be dulness on percussion, 
with feeble or suppressed respiratory sound within 
an area corresponding to the extent of the extravasa- 
tion. "Within and near this area there will be likely 



PULMONARY (EDEMA. • 175 

to be moist bronchial rales more or less fine or coarse. 
The signs of solidification will not be present if the 
extravasation be unaccompanied by pneumonia. 

Pulmonary Gangrene. 

In diffused pulmonary gangrene, the physical signs 
are those of solidification extending over the greater 
part or the whole of a lobe. The diagnosis, however, 
can only be made when, in connection with these 
signs, there are present the characteristic fcetor of 
the breath and expectoration. 

In circumscribed gangrene there is dulness or flat- 
ness on percussion within an area corresponding to 
the extent of the affection, with either suppression 
of respiratory sound, or bronchial respiration, and 
the vocal signs of solidification. Within and near 
this space moist bronchial rales are likely to be heard. 
The situation is usually on the posterior aspect of the 
chest. These signs do not suffice for a positive diag- 
nosis, without the characteristic breath and expecto- 
ration. Cavernous signs may appear after the gan- 
grenous portion of lung has sloughed away, and been 
expectorated. 

Pulmonary (Edema. 

The physical condition expressed by the term pul- 
monary oedema is the presence of effused serum with- 
in the air vesicles. With this condition is associated 
more or less pulmonary congestion. 

In cases of pulmonary oedema developed rapidly 
and largely in connection with renal disease, with 
obstruction at the mitral orifice of the heart, or with 
both these affections combined, giving rise to great 



176 PHYSICAL DIAGNOSIS. 

dyspnoea, and liable to end speedily in death, the 
following are the diagnostic signs : dulness on per- 
cussion on both sides of the chest, especially over 
the lower lobes, fine bubbling or the subcrepitant 
rale diffused over the chest on both sides, together 
with coarser bubbling sounds, and the murmur of 
respiration notably weak or suppressed over the 
lower lobes. Inasmuch as the lungs are not solidi- 
fied, the rales are low in pitch. The vocal signs of 
solidification are, of course, wanting. Occasionally 
the crepitant rale is mingled with the fine bubbling 
sounds. 

This form of the affection is to be differentiated 
from hydrothorax with large effusion, and from so- 
called capillary bronchitis. Hydrothorax is always 
associated with more or less anasarca or general 
dropsy, whereas, pulmonary oedema, even when de- 
pendent on renal disease, may occur without drop- 
sical effusion elsewhere. Moreover, the presence of 
liquid within the pleural cavities, and its amount, 
may always be determined demonstratively in cases of 
hydrothorax {vide Pleurisy with Effusion and Hydro- 
thorax). Capillary bronchitis occurs chiefly in chil- 
dren. The subcrepitant rale on both sides of the 
chest is the diagnostic sign of this affection ; but it 
is not accompanied by dulness on percussion except 
in so far as the bronchitis may be associated with 
lobular pneumonia or collapse of pulmonary lobules. 
The rapid development of the oedema and its patho- 
logical connections, are diagnostic points to be taken 
into account. 

Pneumonia is excluded by the fact that the affec- 



CARCINOMA OF LUNG. 177 

tion is at the beginning bilateral, and by the absence 
of the signs of solidification of lung. 

Pulmonary oedema less in degree and diffusion 
has, of course, the same signs, not as marked and not 
as extensive, namely, dulness on percussion and fine 
bubbling sounds or the subcrepitant rale. In this 
form the affection is bilateral, and seated especially 
in the posterior and inferior portions of the lungs. 
Moreover, this form has the same pathological con- 
nections, namely, with disease of the kidneys, and 
mitral lesions of the heart. The low pitch of the 
bronchial rales, and the absence of the respiratory 
and vocal signs of solidification, together with the 
fact of the affection being bilateral, and the coexist- 
ence of disease of the heart or kidneys, constitute 
the basis of a positive diagnosis. 

Hypostatic congestion of the lungs may occasion 
a certain amount of pulmonary oedema. The physi- 
cal diagnosis is to be based on bilateral dulness on 
the posterior aspect of the chest, with low-pitched 
fine bubbling sounds or the subcrepitant rale on 
both sides, these signs occurring under circumstances 
which lead to the supposition of this form of conges- 
tion. 

Carcinoid a of Lung". Tumors within the Chest. 

Carcinomatous growths in the lungs are usually 
in the form of nodules varying in size from that of 
a pea to a hen's egg, disseminated throughout one 
lung or both lungs in greater or less numbers. These 
disseminated nodules, if of small size, have no well- 
marked, definite diagnostic signs. If limited to a 
lung, or if more numerous in one lung, they may 



178 PHYSICAL DIAGNOSIS. 

occasion an appreciable d illness on percussion. They 
may also occasion feebleness of the respiratory mur- 
mur, and, owing to coexisting circumscribed bron- 
chitis, moist bronchial rales maybe heard at different 
points. These signs warrant a diagnosis when, as is 
usually the case, cancer is known to have existed 
elsewhere. "With reference to diagnosis, it is to be 
borne in mind that, when cancer of the lung is 
secondary, both lungs are affected, and, when it is 
primary, the affection is generally unilateral. 

If there be nodules of considerable size, there will 
be well-marked dulness on percussion in different 
situations, and the signs of solidification may be 
present, namely, bronchial or broncho- vesicular respi- 
ration, increased vocal resonance or bronchophony, 
and increased vocal fremitus. 

In some cases of unilateral carcinoma, the greater 
part, or the whole, of a lung may be infiltrated with 
the*morbid growth, increasing its volume and giving 
rise to enlargement of the affected side, diminished 
respiratory movements or immobility, flatness on 
percussion with diminished or suppressed respiratory 
murmur, vocal resonance, and fremitus. If, as is 
usual, there be also more or less pleuritic effusion, 
the intercostal spaces may be pushed out to a level 
with the ribs. Here are the signs which denote 
chronic pleurisy with large effusion, and the differ- 
ential diagnosis cannot be made with positiveness 
until the fluid within the chest be withdrawn, and 
it be found that, irrespective of the bulging of the 
intercostal spaces, the physical signs remain. Ex- 
ploration with a small trochar will settle the diag- 



CARCINOMA OF LUNG. 179 

nosis when there is no pleuritic effusion, and this 
procedure is unobjectionable. 

In other cases the carcinomatous growth induces 
atrophy of the lung, diminishing its volume, and 
causing notable contraction of the affected side. 
The appearances on inspection are those which 
denote contraction after chronic pleurisy, and which 
may be present also in cases of cirrhosis of lung. 
The differential diagnosis must be based chiefly on 
diagnostic points relating to the history and symp- 
toms. 

Tumors within the chest, generally having their 
points of departure in the mediastinum, displace the 
lung in proportion to their size. They may cause 
considerable displacement of the heart, and produce 
more or less enlargement of the chest with dimin- 
ished respiratory movements. Over the site of the 
tumor, there will be dulness or flatness on percussion. 
Generally respiratory sound is wanting, vocal reso- 
nance and fremitus being either diminished or sup- 
pressed. In the neighborhood of the primary bronchi 
and over lung compressed by the tumor, there may 
be bronchial respiration, with bronchophony and 
increased fremitus. If the chest he enlarged, its 
enlargement is not likely to be as uniform as when 
it is dilated with liquid ; this is a diagnostic point. 
The tumor, or the tumors, may not be confined to 
one side of the chest. It is to be borne in mind that 
pleurisy with effusion may exist as a complication, 
and this may serve to obscure the diagnosis. 

The physical diagnosis involves differentiation 
from pericarditis with effusion and-aneurisms. These 



180 PHYSICAL DIAGNOSIS. 

affections are to be excluded by the absence of their 
diagnostic signs. 

Acute Miliary Tuberculosis. 

The physical condition in this affection is the 
presence of a large number of the small bodies known 
as tubercles or miliary granulations disseminated 
throughout both lungs. Bronchitis is an associated 
affection. 

If the tubercles be about equally distributed in the 
two lungs, there is no abnormal disparity of the 
resonance on percussion between the two sides of 
the chest. A comparison, also, of the two sides may 
afford no disparity as regards the respiratory mur- 
mur, vocal resonance, and fremitus. Moist rales, due 
to the associated bronchitis, may be present in differ- 
ent situations. A physical diagnosis, under these 
circumstances, cannot be made with positiveness. 
Physical exploration, however, is important, in order 
to exclude other affections ; and the negative result, 
taken in connection with the symptoms — hyper- 
pyrexia, rapid pulse, accelerated breathing, etc. — ■ 
renders the diagnosis extremely probable. The dif- 
ferential diagnosis involves discrimination from 
capillary bronchitis, and an essential fever with a 
bronchial complication. The affection has been re- 
peatedly mistaken for typhoid fever. 

The tubercles may be more abundantly distributed 
in one lung. A disparity in the resonance on per- 
cussion may then be apparent, and, perhaps, an 
abnormal increase of vocal resonance and fremitus. 
These signs, taken in connection with the symptoms, 
establish the physical diagnosis. 



PHTHISIS. 181 



Phthisis. 



With reference to physical diagnosis, cases of 
phthisis may be conveniently distributed into three 
groups, as follows : 1st. Cases in which the pulmo- 
nary affection is small, or cases of incipient phthisis; 
2d. Cases in which the affection is moderate or con- 
siderable ; and 3d. Cases in which the affection has 
progressed to the formation of cavities, or cases of 
advanced phthisis. 

In cases of incipient phthisis, the essential physical 
condition is the presence of small solidified masses, 
or nodules, the intervening vesicular structure not 
being affected. These nodules vary from the size of 
a pea to a filbert. In the vast majority of cases they 
are situated at or near the apex of either the right 
or the left lung. Generally, circumscribed capillary 
bronchitis coexists in proximity to the nodules. An 
intercurrent circumscribed ordinary pneumonia some- 
times occurs, giving rise to transient solidification 
within a limited area. Dry circumscribed pleurisy, 
situated over the affected portion of lung, generally 
occurs from time to time. 

In the cases of a moderate or a considerable pul- 
monary affection, the difference, as compared with 
the preceding group of cases, consists in the presence 
of nodules of larger size, or solidification from the 
phthisical deposit extending over a space, or spaces, 
sufficient in size to give rise to well-marked physical 
signs. The solidification in these cases may be 
extended by the development of circumscribed 
interstitial pneumonia. The circumscribed bron- 
chitis is greater, as a rule, in degree and extent ;. 
16 



182 PHYSICAL DIAGNOSIS. 

attacks of dry pleurisy may continue to occur, and 
the pleural surfaces become adherent. In these 
cases, generally, the affection, existing primarily in 
one lung, now exists in both lungs. The volume of 
the lung first affected, at the summit, is more or less 
diminished. Enlargement of the bronchial glands 
is usual, and these may be so situated as to press 
upon and diminish the calibre of one of the primary 
bronchi. In some cases, portions of lung in the 
neighborhood of solidified masses or nodules are 
emphysematous (lobular emphysema). 

Cases of advanced phthisis are characterized by 
the presence of a cavity, or, commonly, of cavities, 
varying in number, size, rigidity or flaccidity of the 
walls, freedom of communication with bronchial 
tubes, and their situation relatively to the super- 
ficies of the lung. In cases of progressive phthisis, 
in addition to cavities, there is more or less solidifi- 
cation from phthisical exudation and interstitial 
pneumonia. The volume of the lung at the summit 
is often notably diminished. The pleural surfaces 
are firmly adherent. If, however, the disease has 
been retrogressive, there may be little or no solidifi- 
cation of lung, the cavity or cavities forming the 
only lesion. In cases of advanced phthisis, with 
very rare exceptions, both lungs are affected, and 
cavities often exist on both sides. 

The physical diagnosis in cases of incipient 
phthisis embraces what may be called direct and 
accessory signs. The accessory signs are those which 
represent incidental affections, namely, circumscribed 
bronchitis, pleurisy, and pneumonia. The direct 



PHTHISIS. 183 

signs are those representing the essential condition, 
namely, the solidified masses or nodules. 

An important direct sign is dulness on percussion. 
Slight dulness on percussion at the summit of the 
chest, in front or behind, is a highly important sign, 
taken in connection with symptoms, of incipient 
phthisis. In determining that a relative dulness is 
abnormal, the student must bear in mind, in the 
first place, the normal disparity between the two 
sides. The right side at the summit is relatively 
somewhat dull on percussion in healthy persons. 
Due allowance is to be made for this normal dis- 
parity. In the second place, it is to be borne in 
mind that any deformity affecting the symmetry of 
the chest will affect the relative resonance on the 
two sides ; and that a deviation from symmetry 
attributable to the position of the patient will occa- 
sion a disparity on percussion- In the third place, 
the rules for the practice of percussion must be kept 
in mind, in order to avoid producing a disparity by 
the non-observance of these rules (vide p. 54). Nor- 
mal resonance on percussion on the two sides is a 
strong point for the exclusion of incipient phthisis. 

The direct respiratory signs in incipient phthisis 
are the broncho-vesicular respiration and weakened 
vesicular murmur. Of course, familiarity with the 
characters of the broncho-vesicular respiration is 
indispensable — the combination of the vesicular and 
the tubular quality in the inspiratory sound, with 
the pitch raised in proportion to the amount of 
tubularity, and the expiratory sound more or less 
prolonged, high, and tubular. Not infrequently the 
only appreciable morbid modification is diminished 



184 PHYSICAL DIAGNOSIS. 

intensity of the murmur. When this sign is present, 
it is probable that the lack of intensity is the reason 
for the absence of the characters of the broncho- 
vesicular modifications ; that is, the latter sign would 
have been present were the respiratory sounds more 
intense. 

The direct vocal signs in incipient phthisis are, 
increased vocal resonance, increased bronchial whis- 
per, and increased fremitus. The other direct signs 
may be present, without an appreciable morbid in- 
crease of the vocal resonance or fremitus. The 
increased whisper may also be wanting, but more 
rarely than the two other vocal signs. 

In deciding on the presence or absence of each 
and all of these direct signs, it is essential to know 
and to judge correctly of the disparity between the 
two sides of the chest at the summit in health. 
Normally, the resonance on percussion at the summit 
on the right side is slightly dull as compared with 
the left side; the inspiratory sound on this side has 
some tubularity in quality, and is somewhat raised 
in pitch ; the expiratory sound may be more or less 
prolonged, high, and tubular; the vocal resonance, 
on the right side, is always greater, the same being 
true of fremitus ; the bronchial whisper is louder on 
the right side, and the intensity of the respiratory 
murmur is a little less on this side. Whenever it is 
a question as to a small phthisical affection at or 
near the apex of the right lung, it is a matter of ex- 
perience and judgment to decide if the disparity in 
respect of these points be greater than normal ; and 
it is not always easy to come at once to a decision. 
From the want of a proper appreciation of the 



PHTHISIS. 185 

several points of disparity in health, it is not un- 
common for an erroneous diagnosis of phthisis to he 
hased thereon. Appreciating the normal points of 
disparity, it is obviously easier to determine that 
the several direct signs of incipient phthisis are 
present at the left, than at the right, summit ; rela- 
tive dulness on percussion, broncho-vesicular or 
weakened respiration, increased vocal resonance, 
whisper, and fremitus, at the left summit, are, of 
course, always abnormal. 

In connection with the foregoing direct signs may 
be mentioned another sign which is often available, 
namely, an abnormal transmission of the heart- 
sounds. This sign is available only in the central 
portion of the infra-clavicular region. A slight de- 
gree of solidification of the summit of one lung 
renders the heart-sounds more audible in the situa- 
tion just named. It is of assistance in determining 
this sign, to be familiar with the following points of 
disparity which exist in health: on the right side 
the second sound of the heart is somewhat more 
audible than on the left side, and on the left side the 
first sound is a little louder than on the right side. 
Hence, if the first sound be better conducted on the 
right than on the left side, it is abnormal ; and if 
the second sound be louder on the left side, it is ab- 
normal. This sign is always to be taken in connec- 
tion with other direct signs ; it gives greater diag- 
nostic strength to the latter, but it is by no means, 
in itself, sufficient for the diagnosis. 

Corroborative evidence of incipient phthisis may 
be obtained by the presence of accessory signs. 
These are, first, fine bubbling or the subcrepitant 

16* 



186 PHYSICAL DIAGNOSIS. 

rale at the summit on one side. This sign denotes 
a circumscribed capillary bronchitis, and this, at the 
summit on one side, is usually associated with 
phthisis. Second, a crepitant rale at the summit on 
one side denotes a circumscribed pneumonia which 
is usually secondary to phthisis. Third, a pleuritic 
friction sound limited to the summit on one side is 
evidence of a dry circumscribed pleurisy which oc- 
curs often in the early stage of phthisis. Fourth, 
indeterminate rales, crumpling, and crackling, are 
significant of phthisis if limited to the summit on 
one side. These rales, it is to be recollected, are 
sometimes found in healthy persons on forced breath- 
ing, especially if the binaural stethoscope be em- 
ployed. If they be normal they are found on both 
sides. The accessory signs are not sufficient for a 
positive diagnosis if they exist alone; but they are 
to be considered as corroborating evidence derived 
from the direct signs, together with the symptoms 
and history. 

As regards differential diagnosis, the affections 
with which incipient phthisis are likely to be con- 
founded, are chronic bronchitis, and moderate em- 
physema. With respect to the first of these affec- 
tions, namely, chronic bronchitis, the differentiation 
must depend on the presence or the absence of posi- 
tive signs of phthisis ; in other words, phthisis is 
either diagnosticated or excluded. The physical 
signs in cases of moderate emphysema sometimes 
lead to the error of supposing this affection to be 
phthisis. Owing to the relatively greater intensity 
of the resonance on percussion at the left summit, 
dulness is thought to exist at the right summit, and 



PHTHISIS. 187 

a prolonged expiration, with the normally greater 
vocal resonance at the right summit, are set down as 
signs of phthisis. This error may be avoided by a 
careful study of the signs of emphysema and the 
normal disparity in respiration, vocal resonance, and 
fremitus, existing between the two sides of the 
chest. 

The physical diagnosis of a phthisical affection 
which is considerable or moderate in amount, is, in 
most cases, an easy problem. Inspection often 
furnishes marked signs. The upper anterior portion 
of the chest on one side is depressed or flattened, and 
the superior costal movements of respiration are 
diminished, the chest elsewhere being symmetrical 
in botli size and motions. There is more or less 
marked dulness on percussion at the upper part of 
the chest on the affected side. Sometimes the 
diminished resonance is tympanitic in quality 
(tympanitic dulness) without the existence of cavi- 
ties, the resonance being conducted from the primary 
and secondary bronchial tubes. The respiration is 
bronchial, or broncho-vesicular approximating more 
or less to the bronchial. Occasionally, however, the 
respiratory sounds are too feeble for their characters 
to be appreciated. There is bronchophony, or the 
vocal resonance is notably increased without the 
bronchophonic characters. The whisper is either 
distinctly bronchophonic or it is notably increased 
in intensity, high in pitch, and tubular in quality. 
Yocal fremitus is often increased. Moist bronchial 
rales, coarse or fine, are generally present. With 
these diagnostic signs on one side, the signs of a 



188 PHYSICAL DIAGNOSIS. 

smaller amount of disease are generally present on 
the other side. 

In some eases of a moderate phthisical affection, 
the judgment may be confused by the resonance on 
percussion being increased or vesiculotympanitic 
on the affected side. This sign denotes the coexist- 
ence of lobular emphysema developed in the progress 
of phthisis. The diagnosis of the latter affection is 
then to be based on the signs obtained by ausculta- 
tion. 

In advanced phthisis the physical diagnosis of the 
disease is sufficiently easy. The signs distinctive of 
this stage of the disease are those which denote 
pulmonary cavities, namely, tympanitic resonance 
on percussion within a circumscribed space; cracked 
metal or amphoric resonance ; cavernous respiration ; 
cavernous whisper and sometimes pectoriloquy ; am- 
phoric respiration and voice, and gargling {vide 
Chapter V. for descriptions of these signs). 

The cavernous signs are generally associated with 
the signs of solidification. In some cases, however, 
in which the disease has been non-progressive and 
retrogressive, the cavernous signs are present with- 
out the signs which denote solidification of lung. 

Fibroid Phthisis, Interstitial Pneumonia, or Cirrhosis 
of Lung. 

In this affection the physical conditions are, solidi- 
fication from hyperplasia of the interstitial pulmonary 
tissue, dilatation of bronchial tubes (bronchiectasis) 
and diminished volume of the lung affected. The 



DIAPHRAGMATIC HERNIA. 189 

affection, as a rule, is limited to one side. The whole 
of a lung, or only a portion of it, may be affected. 
Bronchitis always coexists. 

There is notable dulness on percussion, the dimi- 
nished resonance being sometimes tympanitic. The 
degree of resonance may vary at different exami- 
nations, owing to differences in the amount of 
morbid products within the bronchial tubes. The 
respiration is bronchial, or broncho-vesicular. At 
times from obstruction of bronchial tubes, it may be 
suppressed. Bronchophony and increased vocal 
resonance are the vocal signs, together with the corre- 
sponding whispering signs. The affected side of the 
chest becomes contracted either entirely or in part, 
resembling in this respect the appearances after 
chronic pleurisy. 

With these signs the affection is to be differentiated 
from, the ordinary form of phthisis, by reference to 
points pertaining to the symptoms and history. 

Diaphragmatic Hernia. 

The j^resence of more or less of the hollow abdominal 
viscera within the thoracic cavity in consequence of 
a congenital deficiency of a portion of the diaphragm, 
or perforation from accidents, or enlargement of the 
natural openings, gives rise to certain anomalous 
signs, namely, a tympanitic resonance, variable at 
different times owing to differences as regards the 
quantity of gas within the viscera ; absence of the 
respiratory murmur from the base of the chest up- 
ward, the height proportional to the space occupied 
by the abdominal organs, and the intestinal sounds 



190 PHYSICAL DIAGNOSIS. 

emanating; from within the chest, not conducted from 
below. 

This extremely rare affection can only be con- 
founded with pneumothorax. The latter affection 
is to be excluded by the absence of its diagnostic 
signs, irrespective of the tympanitic resonance on 
percussion. 



CHAPTER VII. 

THE PHYSICAL CONDITIONS OF THE HEART IN 
HEALTH AND DISEASE. THE HEART-SOUNDS 
AND CARDIAC MURMURS. 

Physical conditions of the heart in healih : — Boundaries of the praecordia 
— Normal situation of the apex-beat — Boundaries of the deep and of 
the superficial cardiac space — Relations of the aorta and the pulmonary 
attery to the walls of the chest — The heart-sounds — Characters dis- 
tinguishing the first and the second sound — Mechanism of the produc- 
tion of the heart-sounds — Auscultation of the pulmonic and the aortic 
second sound separately — Movements of the auricles and ventricles in 
relation to each other — Physical conditions of the heart in disease : — 
Enlargement of the heart — Hypertrophy and dilatation — Abnormal 
impulses of the heart, and modifications of the apex-beat — Valvular 
lesions — Roughness of the pericardial surfaces — Liquid within the 
pericardial sac — Abnormal modifications of the heart-sounds — Redupli- 
cation of heart-sounds — Cardiac murmurs — Normal and abnormal 
blood-currents -within the heart, and their relations with the heart- 
sounds — Mitral direct murmur — Mitral regurgitant murmur — Mitral 
systolic non-regurgitant, or intra ventricular murmur — Aortic direct 
murmur — Aortic regurgitant murmur, and an aortic diastolic non- 
regurgitant murmur — Coexisting endocardial murmurs — Tricuspid 
direct murmur — Tricuspid regurgitant murmur — Pulmonic direct 
murmur — Pulmonic regurgitant murmur — Facts of practical importance 
in relation to endocardial murmurs — Pericardial or friction murmur. 

Before entering upon the study of the physical 
diagnosis of the diseases of the heart, the student 
must he familiar with its anatomy and physiology. 
For a description of the structure and functions of 
this organ, he is referred to anatomical and physio- 
logical treatises. The plan of this work embraces 
the anatomical relations of the heart and the space 
which it occupies within the chest, as physical con- 
ditions of health determinable by normal signs, 



192 THE HEART. 

together with the heart-sounds. Having briefly 
stated these conditions of health, the morbid physical 
conditions which may be ascertained by percussion, 
auscultation, and other methods of physical explora- 
tion, will be considered. The latter heading will 
include an account of the cardiac murmurs. 

The Physical Conditions of the Heart in Health. 

The Prazcordia. The Superficial and the Deep Cardiac 
Space. — The area on the surface of the chest corre- 
sponding to the space which the heart occupies within 
the chest, is the precordial region, or the prsecordia. 
The upper, lower-, and two lateral boundaries of this 
region must be memorized. The upper boundary is 
the third rib, the lower is a horizontal line passing 
th rough the fifth intercostal space ; the left lateral 
boundary is at, or a little within, a vertical line 
passing through the nipple, the linea mammalis, and 
the right lateral boundary is represented by a vertical 
line situated about a finger's breadth to the right of 
the right margin of the sternum. As the volume 
of the heart varies, within certain limits, in different 
healthy persons, the boundaries of the prsecordia are, 
of course, not always exactly the same. The fore- 
going statements are sufficiently accurate for practi- 
cal purposes. 

The horizontal line representing the lower boun- 
dary of the praecordia, intersects the point where the 
apex-beat of the heart is felt. The normal situation 
of the apex-beat must be recollected. In most healthy 
persons the apex-beat is felt in the fifth intercostal 
space a little within the linea mammalis. This is, 
assuming the persons to be sitting or standing ; in 



CONDITIONS OF HEART IN HEALTH. 193 

recumbency on the back the beat sometimes rises to 
the fourth intercostal space, and it is sometimes 
found in the fourth space in the sitting or standing 
position of the body. The distance from the linea 
mammalis varies in different healthy persons ; it is 
sufficiently accurate to say it is a little within that 
line. The force of the apex-beat varies much in 
different healthy persons, owing to other causes than 
the power of the heart's action, such as the amount 
of muscular substance and fat in that situation, the 
width of the intercostal space, the convexity of the 
chest, the relation to the left lung, etc. Allowance 
is to be made for these variations in determining the 
abnormal modifications of the force of the beat, which 
belong among the physical signs of disease. 

Within a portion of the prsecordia the heart is 
uncovered of lung, and in the remaining portion 
lung intervenes between the heart and the walls of 
the chest. The former of these portions is called the 
superficial, and the latter is called the deep cardiac 
space. The deep cardiac space on the right side 
extends to the median line. On the left side the 
lung recedes at a point on the median line on a level 
with the cartilage of the fourth rib, and the anterior 
border of the upper lobe makes an outward curve, 
returning inward at or near the apex of the heart. 
This leaves the heart uncovered within an area 
which, for practical purposes, may be represented by 
a right-angled triangle, the hypothenuse extending 
from the median line on a level with the costal 
cartilage of the fourth rib to the apex of the heart ; 
the right angle formed by the median line and the 
17 



194 THE HEART. 

horizontal line which forms the lower boundary of 
the prsecordia. 

The limits. of the superficial cardiac space may he 
easily defined by percussion. It is only necessary to 
ascertain the curved line formed by the receding 
anterior border of the upper lobe of the left lung. 
A distinct, although not great, dulness on percussion 
marks this border of the lung. The border of the 
lung is as distinctly marked by the abrupt diminu- 
tion of the vocal resonance, if auscultation be made 
with the stethoscope. The outer boundaries of the 
deep cardiac space may also be determined by per- 
cussion ; distinct, although slight, dulness marks 
the limits of the prsecordia. Defining thus the 
boundaries of the praecordia and of the superficial 
cardiac space in healthy persons, makes a good 
practical exercise in percussion. 

Relations of the Aorta and Pulmonary Artery to the 
Walls of the Chest. — The base of the heart, especially 
in connection with auscultatory signs, is generally 
considered to be at the second intercostal space near 
the sternum, this situation being, in reality, just 
above the base. In this situation sounds produced 
at the aortic and the pulmonic orifice are best 
studied, either in health or disease. With reference to 
these sounds, the anatomical relations of the aorta 
and the pulmonary artery to the right and the left 
second intercostal space are of importance. If the 
stethoscojDe be applied in the second intercostal space 
on the right side, close to the sternum, it is very 
near the aorta, and sounds produced at the aortic 
orifice are best heard in this situation. If the 
stethoscope be applied in the second intercostal space 



CONDITIONS OF HEART IN HEALTH. 195 

on the left side, it is very near the pulmonary artery, 
and the sounds produced at the pulmonic orifice are 
best heard in this situation. Reference will be made 
to these two situations in giving an account of the 
heart-sounds in health and disease, and of adventi- 
tious sounds or murmurs. 

The Heart-sounds. — The characters which distin- 
guish, respectively, the first and the second sound of 
the heart are to be studied preparatory to the study 
of the abnormal modifications which are important 
physical signs of disease. It is essential also to be 
able always to make the distinction practically be- 
tween the first and the second sound in order to 
connect with each sound separately cardiac murmurs. 
The conventional sense of the term heart-sounds, as 
distinguished from cardiac murmurs, must be borne 
in mind. The cardiac murmurs are adventitious 
sounds ; they are never merely abnormal modifica- 
tions of the heart-sounds, but they are new sounds 
added to these. 

The two heart-sounds follow in a certain rhythmi- 
cal order, and, in health, this suffices for the recogni- 
tion of each. It answers all practical purposes to 
say that the first and the second sound follow each 
other after an interval which is just appreciable, this 
interval being the short pause of the heart. After 
the two sounds an interval is readily appreciable, 
called the long pause of the heart. It is not neces- 
sary to carry in the memory the exact relative dura- 
tion of each of the sounds and each of the intervals. 
The fractions of a unit, in fact, do not express the 
length of the sounds and intervals as correctly as less 
definite expressions, inasmuch as the figures represent 



196 THE HEART. 

only the mean of variations within the limits of 
health. It is sufficiently definite to say that, with 
the ear or stethoscope applied over the situation of 
the apex-heat, the first sound is longer than the 
second, louder, lower in pitch, and has a quality 
which may he called booming. Per contra, the 
second sound is shorter, weaker, higher in pitch, and 
has a quality which may be called valvular or click- 
ing. Aside from the relative leno-th of the two 
sounds, the other characters are more or less marked 
in different healthy persons. 

These distinctive characters of the heart-sounds 
are apparent when the ear or stethoscope is applied 
over the apex. At the base of the heart, that is, in 
the second intercostal space near the sternum, the 
characters of the first sound are not the same. The 
second sound in this situation is louder than the first. 
This sound is said to be accentuated at the base, the 
first sound being accentuated at the apex. Moreover, 
the first sound at the base may not be longer than 
the second; it loses more or less of its booming 
quality, the pitch remaining lower than that of the 
second sound. Removing the ear or the stethoscope 
a certain distance from the apex in any direction, 
occasions similar changes in the characters of the 
first sound. The interposition of several thicknesses 
of a napkin has the same effect. 

From the differential characters over the apex, and 
the rhythm in other situations, there is no difficulty 
in distinguishing the first from the second sound in 
health. In cases of disease, however, owing to dis- 
turbance of the rhythm, modifications of the charac- 
ters of the first sound, and the absence sometimes of 



CONDITIONS OF HEART IN HEALTH. 197 

one of the sounds, other means of recognition must 
he resorted to. If the apex-heat can he felt, this 
offers a ready way for recognizing the first sound — 
the sound which is synchronous with the apex-beat 
is, of course, the first sound. This mode is not 
always available, inasmuch as the apex-beat cannot 
always be felt. Another mode is always available, 
namely, feeling the carotid pulse. The carotid pulse 
is synchronous with the first sound, whereas there is 
a slight interval between this sound and the radial 
pulse. 

The student is aided in comprehending certain 
physical signs by taking into view the mechanism 
of the production of the heart-sounds. The second 
sound is produced by the sudden forcible closure of 
the aortic and the pulmonic valve. This closure is 
caused by a retrograde movement of the columns of 
blood in the aorta and pulmonary artery, directly 
the ventricular systole is ended. The retrograde 
movement is due to the recoil of the coats of the 
arteries which have been dilated by the column of 
blood moving onward during the ventricular systole. 
This recoil causes regurgitation into the ventricle 
when either the aortic or the pulmonic valve is 
rendered incompetent by lesions. The mechanism 
of the first sound is less simple.' This sound is in 
part due to the forcible tension of the auricular-ven- 
tricular valves, caused by the systole of the ventricles. 
In this way is produced a valvular element of the 
first sound. That the impulsion of heart against 
the walls of the chest furnishes another element 
seems demonstrable. To this element of impulsion 
the first sound is indebted for its greater intensity, 

17* 



198 THE HEART. 

as compared with the second sound, its length, and 
its booming quality. This is shown by the fact, 
already stated, that when auscultation is made at a 
certain distance from the apex, these characters are 
eliminated, and by the fact that diseases which 
diminish or arrest the impulsion movements of the 
heart produce the same modifications. The valvular 
element of the first sound is weaker than the second 
sound, a fact which at first occasions surprise when 
the difference in size between the aortic and pulmonic 
and the auriculo- ventricular valves is considered. 
The explanation of this apparent incongruity is as 
follows: the aortic and pulmonic segments at the 
end of the ventricular systole are in contact with 
the arterial walls, and are expanded when the recoil 
of the latter follows. On the other hand, when the 
ventricular systole takes place in health, the auric- 
ulo-ventricular valves are not in contact with the 
walls of the ventricles, but they are floated out and 
the orifices are nearly or quite closed ; the movement 
of the blood, therefore, in the systole only renders 
these valves tense. The second sound, in other 
words, is due to the expansion of the sigmoid valves 
of the aorta and pulmonary arterj^, whereas, the 
valvular element of the first sound is due to the 
tension of the auriculo-ventricular valves. The 
foregoing points relating to the heart-sounds were 
contained in my prize essay " On the Clinical Study 
of the Heart-Sounds in Health and Disease," published 
in the Transactions of the American Medical Asso- 
ciation in 1858. 1 

1 Vide, also, "Treatise on Diseases of the Heart," first edi- 
tion 1860 ; second edition 1870. 



CONDITIONS OF HEART IN HEALTH. 199 

A point in relation to the second sound of the 
heart has an interesting and important bearing on 
auscultation in disease, namely, the study of this 
sound as produced at the aortic and the pulmonic 
orifice separately. Recalling the anatomical relations 
of the aorta and the pulmonary artery to the walls 
of the chest, if the stethoscope be applied in the 
second intercostal space on the right side close to 
the sternum, the characters of the second sound are 
derived chiefly from the aortic valve, and if the 
stethoscope be applied in the second intercostal 
space on the left side close to the sternum, the 
characters of the second sound are derived chiefly 
from the pulmonic valve. The correctness of this 
statement is proved by differences in the characters 
of the sound on the two sides in health, and by the 
modifications in cases of disease. These morbid 
modifications will enter into the physical diagnosis 
of cardiac affections. In health the aortic second 
sound is somewhat louder, higher in pitch, and the 
valvular quality more marked than the pulmonic 
second sound. The student should verify these 
points of difference by the study of the second sound 
in the two situations just named. In order for the 
comparison to be a fair one in health and available 
in the diagnosis of disease, the normal anatomical 
relations to the walls of the chest, of the aorta, and 
pulmonary artery must be preserved. These rela- 
tions are affected by changes in the symmetry of the 
chest, and sometimes by enlargement of the heart. 
The lungs must also be free from disease ; otherwise, 
the conduction of the sounds will be abnormal. 

The movements of the auricles and the ventricles 



200 THE HEART. 

are to be kept in mind with reference to the under- 
standing of certain physical signs of disease. Points 
of especial importance are the contraction of the 
auricles in the latter part of the long pause of the 
heart, preceding the ventricular systole, and the 
twisting of the heart from left to right in the systole, 
this movement being reversed in the diastole. In 
these systolic and diastolic twisting movements, 
the pericardial surfaces move upon each, but in 
health noiselessly owing to their smoothness and 
moisture. The movements occasion an ausculta- 
tory sound when the surfaces are roughened by the 
presence of lymph. Other points are the size of the 
pericardial sac, that is, its capability of holding when 
filled, but not dilated, from fifteen to twenty ounces 
of liquid, and its attachment, not to the base of the 
heart, but to the vessels above the base. 

Physical Conditions of the Heart in Disease. 

The physical conditions of the heart in disease, 
which are determinable by physical exploration, are, 
1st, enlargement of the heart ; 2d, abnormal impulses 
and modifications of the apex-beat ; 3d, valvular 
lesions; 4th, roughness of the pericardial surfaces; 
and, 5th, liquid within the pericardial sac. Having 
considered these conditions, an account of abnormal 
modifications of the heart-sounds and cardiac mur- 
murs will conclude this chapter. 

Enlargement of the Heart. — Enlargement of the 
heart may be slight, moderate, great, or very great, 
these terms expressing different degrees of enlarge- 
ment with sufficient precision for clinical purposes. 
In cases of very great enlargement, the space within 



CONDITIONS OF HEART IN DISEASE. 201 

the chest which the heart occupies may be from four 
to five times larger than in health. The situation 
of the base of the heart remains but little, or not at 
all, changed in cases of enlargement ; the increased 
space which the heart occupies is therefore down- 
ward. This increased space extends much more to 
the left than to the right ; the left border of the 
heart, in proportion to the enlargement, is carried 
beyond the mammary line on the left side, whereas, 
the right border is carried comparatively but little 
beyond the normal right lateral boundary of the 
pryecordia even when the enlargement is very great. 
The superficial cardiac space is enlarged in propor- 
tion to the enlargement of the heart ; the organ 
pushes to the left the receding anterior border of the 
upper lobe of the left lung, and is proportionately in 
contact, uncovered of lung, with the walls of the chest. 
The apex of the heart is lowered in proportion to the 
enlargement, and it is carried more or less to the left 
of its normal situation. It may be lowered to the 
sixth, seventh, eighth, or ninth intercostal space. 
The enlargement of the heart is rarely equal in all 
its parts. The enlargement may be entirely or chiefly 
of either the right or the left ventricle. Enlargement 
of the right ventricle and auricle tends to carry the 
right side of the heart more to the right than when 
the left ventricle and auricle are enlarged. The 
situation of the apex is also affected by the parts of 
the heart in which the enlargement predominates. 
The apex is carried further to the left of its normal 
situation, other things being equal, when the enlarge- 
ment predominates on the right side of the heart ; 
and it is lowered without being carried far to the 



202 THE HEART. 

left when the enlargement of the left ventricle pre- 
dominates. The apex of the organ in cases of con- 
siderable or of great enlargement becomes changed 
in form ; it is rounded or blunted. This change is 
most marked when enlargement of the right ventri- 
cle predominates. All these points are of importance 
with reference to the comprehension of the physical 
signs of enlargement of the heart. 

Enlargement of the heart may be entirely due 
either to hypertrophy or to dilatation (simple hyper- 
trophy and simple dilatation). If, however, the 
enlargement be sufficient to occasion notable dis- 
turbance of the circulation, both these forms of 
enlargement are usually combined, but, as a rule, 
one or the other form predominating, so that, of the 
cases of disease of the heart which come under medi- 
cal treatment, the majority are cases of either enlarge- 
ment with predominant hypertrophy or enlargement 
with predominant dilatation. 

These widely different physical conditions are con- 
cerned especially in the abnormal impulses and modi- 
fications of the apex-beat, as well as, also, the heart- 
sounds. 

Abnormal Impulses of the Heart, and Modifications 
of the Apex-beat. — The abnormal situation of the apex 
of the heart when enlarged has been stated. Gener- 
ally the situation is determinable by the apex-beat. 
It has been seen that in health the beat is sometimes 
not appreciable by the touch, owing to the thickness 
of the soft parts and the conformation of the thorax, 
and, for these reasons, the force of the beat varies 
much in different healthy persons. Exclusive of 
normal variations, the beat is generally strong and 



CONDITIONS OF HEAET IN DISEASE. 203 

prolonged in proportion as the heart is enlarged by 
hypertrophy. There are exceptions to this state- 
ment, which are to be explained by the altered form 
of the apex ; when it loses its pointed form, it does 
not so readily come into contact with the walls of 
the chest in an intercostal space, and, hence, the heat 
may be weak although the ventricular systole be 
abnormally powerful. On the other hand, the apex- 
beat is weakened by dilatation, and it may be want- 
ing as a result of diminished power of the systole of 
the ventricles. The apex-beat is also abnormally 
weak in fatty degeneration and softening of the 
heart, as well as in functional debility of the organ 
incident to other diseases than those of the heart. 

If there be considerable or great enlargement, the 
heart being in contact with. the walls of the chest 
over a larger area than in health, impulses other than 
the apex-beat are generally apparent to the eye and 
touch. Not infrequently impulses are appreciable in 
each intercostal space between the situation of the 
apex and the base of the heart. These abnormal 
impulses are felt to be strong in proportion as the 
enlargement is due to hypertrophy, and weak in 
proportion as dilatation predominates. Enlargement 
seated in the right ventricle causes an impulse in the 
epigastrium, which is strong or weak in proportion 
as hypertrophy or dilatation predominates. Cardiac 
impulses are felt and seen in abnormal situations 
when the heart is removed from its normal situation 
by the pressure of an aneurism, or other tumor, by 
pleuritic effusion, hydroperitoneum, etc. The error 
of mistaking for a cardiac impulse the pulsation of 
an aneurismal tumor is to be avoided. Another 



204 THE HEART. 

error is to be avoided, namely, mistaking abnormal 
impulses due to the heart being uncovered of lung 
from shrinking of the latter in certain pulmonary 
affections, for impulses denoting enlargement of the 
heart. In cases of enlargement by hypertrophy, a 
heaving movement of the whole praecordia is some- 
times felt when the hand is applied to the chest. A 
violent shock is sometimes felt by the hand applied 
to the prsecordia, but without a sense of increased 
muscular power, in cases of purely functional disorder 
of the heart. 

Valvular Lesions. — The lesions affecting the valves 
of the heart are of a varied character, for an account 
of which the student is referred to treatises on 
cardiac diseases, or on pathological anatomy. It 
suffices here to consider that, with reference to 
physical signs and pathological effects, they may be 
distributed into three groups, as follows : 1st, lesions 
which diminish more or less the size of the orifices, 
or obstructive lesions ; 2d, lesions which render the 
valves more or less incompetent and permit regurgi- 
tation, or regurgitative lesions; and, 3d, lesions 
which roughen the surface over which the blood 
moves, without occasioning either obstruction or 
regurgitation. The latter may be distinguished as 
innocuous lesions, giving rise to no pathological 
effects, although represented by cardiac murmurs. 

It is useful to bear in mind that, in the great 
majority of cases, valvular lesions are seated in the 
left side of the heart, that is, they are either mitral 
or aortic. Tricuspid and pulmonic lesions are com- 
paratively rare, and they are generally congenital. 
Not infrequently mitral and aortic lesions coexist. 



CONDITIONS OF HEART IN DISEASE. 205 

and there may be coexisting lesions at all the orifices 
of the heart. 

Valvular lesions are represented by cardiac mur- 
murs. By means of the murmurs the existence of 
lesions is evidenced, their situation at the different 
orifices may be ascertained, and, generally, it is 
practicable to determine whether they occasion ob- 
struction or regurgitation, or both. These several 
points of inquiry will be considered presently under 
the heading cardiac murmurs, and in connection 
with ■ the lesions of the different valves respectively 
in the next chapter. 

Roughness of the Pericardial Surfaces. — In place of 
the smoothness of the pericardial surfaces in health, 
which permits their movements upon each other 
noiselessly, the presence of the inflammatory product 
lymph, and, in some rare instances morbid growths, 
occasion an adventitious sound or murmur, which 
will be noticed in connection with other murmurs, 
and as entering into the physical diagnosis of peri- 
carditis. 

Liquid within the Pericardial Sac. — More or less 
liquid transudes into the pericardial sac in cases of 
general dropsy or anasarca, but rarely in very large 
quantity. Liquid effusion occurs in acute pericarditis, 
and in this affection the sac may become filled with 
liquid. In some cases of chronic pericarditis the sac 
is greatly dilated by liquid, the quantity amounting 
to four pounds, or even more. 

When the pericardial sac is filled with liquid, 

without being dilated, it forms, virtually, a pyritbrm 

tumor within the chest, the base of which is at the 

sixth or seventh intercostal space ; the apex rises 

18 



206 THE HEAET. 

nearly to the sternal notcli ; the left lateral border 
is considerably beyond the nipple, and the right 
lateral border is more or less beyond the right margin 
of the praecordia. The anterior portion of the filled 
pericardium is mostly uncovered of lung and in con- 
tact with the walls of the chest. Within this area 
there is either notable dulness or flatness on percus- 
sion, together with absence of respiratory murmur 
and of vocal resonance. By means of these signs, 
the boundaries of the pyriform tumor may be readily 
delineated on the surface of the chest. 

When the pericardial sac is partially filled with 
liquid, the same signs are present, but within an 
area of less extent, and the configuration of the pyri- 
form tumor is wanting. 

In cases of chronic pericarditis with a large accu- 
mulation of liquid, the pericardial sac is dilated so 
that its lateral boundaries may extend nearly to the 
axillary and infra-axillary regions. Under these 
circumstances, flatness on percussion, absence of res- 
piratory murmur and of vocal resonance, are present 
over the greater part of the anterior aspect of the 
chest. 

Abnormal Modifications of the Heart-sounds. 

In order to appreciate the abnormal modifications 
of the heart-sounds, their normal characters are to be 
kept in mind (vide page 195), and the student must 
be practically familiar with them. The modifica- 
tions relate especially to the intensity and quality of 
the first and the second sound. Either of the two 
sounds may be suppressed. 

The first sound has all its normal characters 



ABNORMAL MODIFICATIONS OF SOUNDS. 207 

intensified when the power of the ventricular sys- 
tole is increased by hypertrophy. The sound is 
louder than in health ; it is longer, and the booming 
quality is more marked. If obstructive or regurgi- 
tant valvular lesions do not exist, the second sound 
is also intensified, without change in other respects. 
The first sound, when much intensified, sometimes 
has a ringing tone or tinnitus. This is also sometimes 
observed in health when the power of the heart's 
action from any cause is increased. 

In some cases of violent palpitation the first sound 
is notably intense, but short and valvular in quality. 
I suppose the explanation of this to be as follows : 
the ventricles contract with a kind of spasmodic 
action upon a small quantity of blood ; and, under 
these circumstances, the auriculo-ventricular valves, 
not being floated out as they are when the ventricles 
are well filled, expand with force in the ventricular 
systole, instead of being merely made tense as in 
health. Hence, the valvular element of the first- 
sound is much intensified, while those characters of 
the first sound which are due to the impulsion of the 
heart against the walls of the chest, may be feeble or 
wanting. 

Weakening or suppression of the first sound over 
the apex is an effect of those affections of the heart 
which diminish the power of the ventricular sys- 
tole. These affections are enlargement from dilata- 
tion, atrophy, fatty degeneration, and softening. 
If the sound be notably weakened, it becomes short 
and valvular like the second sound. These changes 
show that the characters dependent on the element 
of impulsion are affected more than the valvular 



208 THE HEAET. 

element. Liquid effusion within the pericardium 
renders the first sound more or less weak and valvu- 
lar, the characters derived from impulsion being, 
under these circumstances, wanting. Diminished 
power of the heart's action from other than cardiac 
diseases, involves weakness of both of the heart- 
sounds, but more especially of the first sound. 

The abnormal modifications of the second sound, 
which are chiefly of interest and importance, relate 
to the aortic and pulmonic sound considered sepa- 
rately. Bearing in mind the mode of interrogating 
the aortic and the pulmonic orifice with reference to 
the valvular sound derived from each independently 
of the other {vide page 199), a comparison of the two 
sounds in diseases of the heart affords often useful 
information. AVhenever, from mitral obstruction 
or regurgitant lesions, or both combined, the blood 
propelled by the left ventricle into the aorta is 
diminished, the recoil of the arterial coats, after the 
ventricular systole, is lessened ; consequently, the 
aortic segments expand with less force, and the 
valvular sound is weakened. Diminished intensity 
of the aortic sound thus represents an abnormal 
diminution of the quantity of blood propelled into 
the systemic arteries in the systole of the left ven- 
tricle, and this diminished intensity is, in a measure, 
a criterion of the amount of mitral obstruction or 
mitral regurgitation, or both combined. In some 
cases of extreme obstruction or regurgitation, the 
aortic sound is completely suppressed. How is 
weakening of this sound to be determined and 
measured? By comparison with the pulmonic 
sound. Now, as will presently appear, the pulmonic 



ABNORMAL MODIFICATIONS OF SOUNDS. 209 

sound is apt to be intensified when the aortic sound 
is weakened. Hence, the former is not an accurate 
standard for this comparison ; but it suffices for an 
approximation to accuracy. In cases of hypertrophy 
of the left ventricle without obstructive or regurgi- 
tant valvular lesions, the aortic sound is abnormally 
intensihed. These cases are, however, of rare occur- 
rence. They occur chiefly in connection with fibroid 
or atrophic lesions of the kidneys. 

A simpler cause of weakening or suppression of 
the aortic sound, is damage from lesions of the 
aortic valve. In proportion as the function of this 
valve is impaired by lesions, the intensity of the 
sound is diminished, and if the function of the 
valve be lost, the sound is wanting. In these cases, 
the pulmonic sound being but little or not at all 
affected, it is an accurate standard for the compari- 
son. 

The pulmonic sound is weakened in the rare 
instances of lesions affecting the pulmonic valve. 
This sound is oftener intensified than weakened. 
It is notably intensified when the right ventricle is 
hypertrophied, and especially when this hypertrophy 
is associated with dilatation of the left auricle re- 
sulting from mitral obstruction or regurgitation. 
These lesions weakening, as has just been seen, the 
aortic sound, the contrast between the aortic and 
the pulmonic sound in some cases of mitral lesions 
is very marked. The pulmonic sound is sometimes 
loud while the aortic sound is suppressed. 

In comparing the aortic and the pulmonic sound 
in disease, as in health, it is to be assumed that the 
anatomical relations of the aortic and the pulmo- 

18* 



210 THE HEART. 

nary artery to the second intercostal space on either 
side, close to the sternum, are not materially altered, 
and that the lungs are free from lesions in conse- 
quence of which the conduction of the sound on 
either side is abnormal. 

Returning to the first sound of the heart, the 
mitral and the tricuspid part of the valvular ele- 
ment of this sound may be studied separately. 
"With the stethoscope applied at or a little to the 
left of the apex, the valvular element of the first 
sound, which is heard, is derived chiefly from the 
mitral valve. On the other hand, if the stethoscope 
be applied at or near the right lower border of the 
heart, the valvular element is derived chiefly from 
the tricuspid valve. Rotable weakness or suppres- 
sion of the mitral valvular sound as compared with 
the tricuspid, represents impairment of the function 
of the mitral valve, and, per contra, notable weak- 
ness or suppression of the tricuspid valvular sound 
denotes impairment of the function of the tricuspid 
valve. Allowance, in this comparison, is to be made 
for a normal disparity, the mitral valvular sound 
being louder than the tricuspid, in health. 

Reduplication of Heart-sounds. — The sounds of the 
heart are said to be reduplicated when either the 
first or the second sound is repeated, or when each 
sound occurs twice before the long pause or interval. 
Considering the heart-sounds as represented by the 
whispered words Lub-dup, reduplication of the first 
sound is expressed by Lub lub-dup, of the second 
by Lub-dup dup, and of both sounds by Lub lub- 
dup dup. 

Clinically, reduplication of the second sound is 



ABNORMAL MODIFICATIONS OF SOUNDS. 211 

much more frequent than reduplication of either 
the first sound, or of both sounds. Yet, accepting 
the explanation which seems most reasonable of this 
anomaly, both sounds should always be redupli- 
cated, that is, neither should be reduplicated sepa- 
rately. It is probable that both sounds are always 
reduplicated, but the reduplication of one of them 
(generally the first sound) from its feebleness is not 
appreciable. 

There is a form of disorder which may be con- 
founded with reduplication of both sounds of the 
heart. In this disorder, with every alternate revo- 
lution of the heart, the sounds are weak, and the 
ventricular systole is not represented by a radial 
pulse, the force of the contraction of the ventricle 
being insufficient to cause an appreciable pulsation 
in the remote arteries ; hence, the heart-sounds occur 
twice for each pulse at the wrist. Under these cir- 
cumstances, however, the carotid pulse may gener- 
ally, if not always, be felt with the weak, as well 
as with the stronger, ventricular contraction, and in 
this way the error of confounding the disorder with 
reduplication may be avoided. 

The explanation of reduplication is, that instead 
of the two ventricles contracting in unison, as in 
health, one contracts a little before the other. This 
explanation accounts satisfactorily for the anomaly. 

Reduplication of the heart-sounds may occur in 
connection with cardiac lesions, or there may be no 
evidence of any organic affection. In the latter 
case, the anomaly falls properly among the varied 
forms of functional disorder of the heart. Whether 
or not it be connected with lesions, it has no im- 



212 THE HEART. 

portant pathological significance. It is usually of 
temporary duration. 

Cardiac Murmurs. 

All adventitious, abnormal sounds which are 
added to the heart-sounds, are embraced by the term 
cardiac murmurs. Let it be borne in mind that, 
conventionally, the murmurs are never abnormal 
modifications of the heart-sounds, but always newly 
produced sounds, and they always represent morbid 
conditions of either the heart or the blood. When 
due to morbid conditions of the blood, they are 
called inorganic, anaemic, haamic murmurs, and 
when they represent valvular lesions or changes 
within the heart, they are distinguished as organic 
murmurs. 

The organic murmurs may be distributed into 
three groups after differences in quality, namely, 
1st, soft; 2d, rough; and 3d, musical murmurs. 
The soft murmurs resemble the sound produced by 
air from the nozzle of a pair of bellows, and, hence, 
are often called bellows murmurs. Murmurs are 
said to be rough when their qualities may be ex- 
pressed by such terms as rasping, grating, creaking, 
croaking, etc. They are called musical when the 
sound is a musical note. The bellows murmurs are 
of most frequent occurrence, and the musical are 
much more rare than the rough murmurs. The 
quality of a murmur does not in general invest it 
with any special pathological or diagnostic signifi- 
cance. The murmurs vary in pitch, being either 
relatively high or low. The variations in pitch are 



CARDIAC MURMURS. 213 

useful in aiding to discriminate different coexisting 
murmurs. 

This account of organic murmurs applies to those 
produced at the orifices or within the cavities of the 
heart. They are distinguished as endocardial mur- 
murs. Adventitious sounds are, however, produced 
upon the external surface of the heart. These con- 
stitute what is called exocardial, pericardial, or 
friction murmur. 

Endocardial murmurs are produced hy "blood- 
currents pursuing either a normal or an abnormal 
direction. With a familiar knowledge of these 
currents, and of their relations with the heart- 
sounds, the several endocardial murmurs are very 
easily understood, as regards points involved in their 
differentiation from each other. The student is, 
therefore, advised first to become acquainted with 
the blood-currents, in health and in disease. Di- 
recting the attention to the left side of the heart, 
there are two normal blood-currents, namely, the 
current from the left auricle to the left ventricle, 
and the current from the left ventricle into the 
aorta. These may be distinguished as the direct 
currents. The first is the mitral direct current, and 
the second is the aortic direct current. Two abnor- 
mal currents may occur in the left side of the heart. 
These currents can only take place when the valves 
are rendered incompetent by lesions. The incom- 
petency of the valves allows of regurgitation, and 
these abnormal currents may be distinguished as 
the regurgitant currents. One of these is a current 
backward from the left ventricle into the left 
auricle, owing to incompetency of the mitral valve ; 



214 THE HEART. 

this is the mitral regurgitant current. The other 
is a current backward from the aorta into the left 
ventricle, arising from incompetency of the aortic 
valve ; this is the aortic regurgitant current. 

What are the relations of these four currents in 
the left side of the heart with the heart-sounds? 
The mitral direct current takes place when the 
auricles contract. The contraction of the auricles 
precedes the ventricular systole. The ventricular 
systole is synchronous with the first sound of the 
heart. The mitral direct current, therefore, takes 
place just before the first sound of the heart. It 
begins after the second sound, and continues until it 
is suddenly and completely arrested by the contrac- 
tion of the ventricle. It is obvious that the current 
cannot continue during the ventricular contraction, 
that is, when the first sound of the heart is produced. 
The mitral regurgitant current is caused by the con- 
traction of the ventricle ; the current, therefore, must 
take place with the first sound of the heart. This 
current is systolic in the time of its occurrence. 
The aortic direct current, being caused by the con- 
traction of the left ventricle, takes place with the 
first sound of the heart. It is, therefore, coincident 
with the mitral regurgitant current. The aortic 
regurgitant current is caused by the recoil of the 
arterial coats upon the column of blood within the 
aorta directly after the ventricular systole, and as 
this recoil causes the second sound of the heart, the 
current and this sound must be coincident. 

Recapitulating the relations of the four currents 
with the heart-sounds, the aortic direct and the 
mitral regurgitant take place with the first sound — 



CARDIAC MURMURS. 215 

they are systolic currents ; the mitral direct current 
precedes the first sound — it is presystolic, and the 
aortic regurgitant current takes place with the 
second sound — it is diastolic. 

Analogous blood-currents take place in the right 
side of the heart, and have corresponding, relations 
with the heart-sounds. These currents are the tri- 
cuspid direct, the tricuspid regurgitant, the pulmonic 
direct, and the pulmon i c regurgitant. The pulmonic 
regurgitant is exceedingly rare in consequence of the 
infrequency of pulmonic lesions ; but the tricuspid 
regurgitant is not uncommon, and probably occurs 
without valvular lesions or enlargement of the heart 
when the right ventricle is distended with blood, 
constituting what has been called the "safety 
valve function" of the tricuspid orifice. 

Organic endocardial murmurs are produced by 
the foregoing direct and regurgitant blood currents, 
and they are designated by the same names, that is, 
they are either direct or regurgitant. Thus, there 
are produced in the left side of the heart — the side 
in which vulvular lesions are seated in the great 
majority of cases — a mitral direct murmur, a mitral 
regurgitant murmur, an aortic direct murmur, and 
an aortic regurgitant murmur. In the right side of 
the heart there may be produced corresponding 
murmurs, namely, a tricuspid direct, a tricuspid 
regurgitant, a pulmonic direct, and a pulmonic 
regurgitant. It remains to point out the means 
of differentiating these several murmurs aside from 
their relations with the heart-sounds. 

Mitral Direct Murmur. — This murmur is presys- 
tolic. It begins after the second sound and ends 



216 THE HEAET. 

abruptly with the first sound. Almost invariably 
this murmur is rough in quality ; occasionally it is 
a soft bellows murmur. When rough it is often quite 
loud. The rough quality is peculiar ; it is suggestive 
of vibration, and may -be imitated by causing the 
lips or the tongue to vibrate with the breath in ex- 
piration. I state the mechanism of this murmur, 
inasmuch as the explanation is original with me, 
and has not been as yet generally accepted. It is 
caused by the vibration of the mitral curtains, and 
takes place especially when these curtains are united 
at their sides, leaving a narrowed orifice through 
which the mitral direct current of blood flows. 
Throwing the lips into vibration with the breath, 
represents not only the quality of the murmur, but 
the mode of its production. The physical conditions 
which are requisite generally for its production are 
a narrowed mitral orifice, and flaccidity of the mitral 
curtains. The latter of these conditions does not 
always exist in cases of mitral obstructive lesions, 
and, hence, the murmur by no means always accom- 
panies these lesions. When it is considered how 
loud a blubbering sound may be produced by the 
vibration of the lips with a feeble current of air, 
it is not difficult to understand that an intense 
murmur may be caused by a current of blood pro- 
pelled by the comparatively weak contraction of the 
auricle. 

A mitral direct murmur may be produced with- 
out mitral lesions, the murmur having the same rough 
quality as when lesions exist, and being, also quite 
loud. This statement, based on clinical proof, was 
made by me many years since, together with the 



CARDIAC MURMURS. 217 

explanation. It occurs when there are aortic lesions 
which permit free regurgitation. Under these cir- 
cumstances, at the time when the auricular contrac- 
tion takes place, the left ventricle is already filled 
with blood ; the mitral curtains are floated out so 
as to be in contact with each other, and the mitral 
direct current passing between the curtains throws 
them into vibration precisely as when the orifice is 
narrowed. The vibration of the lips when lightly 
in contact, caused by the expired breath, illustrates 
the manner in which a mitral direct murmur takes 
place without mitral lesions. The murmur, thus 
occurring without mitral lesions, is not constant ; it 
is now present and now absent, depending, as it does, 
on the quantity of blood within the left ventricle 
at the time of the contraction of the auricle. It 
follows from what has just been stated, that a mitral 
direct murmur is not always a sign of mitral obstruc- 
tive lesions, when there is free aortic regurgitation. 

This murmur is limited to a circumscribed space 
around the apex of the heart. However loud the 
murmur may be in this situation, it is lost within 
a short distance from the apex. 

A mitral direct murmur is never due to a morbid 
condition of the blood. Although it occurs without 
mitral lesions, yet, inasmuch as its occurrence then 
requires the existence of aortic regurgitant lesions, 
it cannot be said to be an inorganic murmur. 

Mitral Regurgitant Murmur ; Mitral Systolic Non- 
regurgitant, or Intra-ventricular Murmur. — The 
mitral regurgitant murmur, synchronous with the 
first sound, that is, a systolic murmur, may be soft, 
rough, or musical in quality, its intensity and pitch 
19 



218 THE HEART. 

being variable. Aside from its relation with the 
first sound of the heart, it is distinguished by having 
its maximum of intensity at or near the situation of 
the apex-beat. It may be limited to a circumscribed 
area, and if heard at a distance from the apex, it is 
best transmitted laterally around the left side of the 
chest. It is often heard on the posterior aspect of 
the chest on the left side near the lower angle of the 
scapula, and not infrequently in the corresponding 
situation on the right side. 

A murmur with the first sound heard within a 
limited area at the apex, may be due to roughness of 
the endocardial membrane without mitral incompe- 
tency, and, consequently, without a mitral regurgi- 
tant current. This is a mitral systolic non-regurgi- 
tant murmur. It may also be called an intra- ven- 
tricular murmur, being produced, not at the mitral 
orifice, but within the ventricle. This murmur 
cannot always be discriminated from a feeble mitral 
regurgitant murmur. If, however, a mitral murmur 
be conducted laterally for some distance to the left 
of the apex, and if it be heard on the back, it may 
be considered to represent mitral regurgitation. A 
mitral systolic, non-regurgitant, or intra-ventricular 
murmur, is the murmur present in endocarditis. 

It is probable that the impulse of the apex of the 
heart against the adjacent portion of lung some- 
times forces the air from the air vesicles sufficiently 
to give rise to a blowing sound occurring with each 
ventricular systole. This is liable to be confounded 
with an endocardial murmur. Produced in the way 
just stated, it may be heard only during the act of 
inspiration, and especially at the end of this act. 



CARDIAC MURMURS. 219 

A mitral systolic murmur is rarely, if ever, due to 
an abnormal condition of the blood, without any 
anatomical change in the valve or endocardial 
membrane. Conditions of the blood, however, 
which are favorable for the production of inorganic 
murmurs, may intensify this murmur as well as any 
of the organic murmurs. 

Aortic Direct Murmur. — -This murmur, like the 
mitral regurgitant, and the mitral systolic non-re- 
gurgitant murmur, occurs with the first sound of the 
heart, that is, it is systolic. Of the organic murmurs 
in the left side of the heart, the murmurs just named 
and the aortic direct murmur, are synchronous, the 
others having different relations with the heart- 
sounds. The aortic direct murmur differs from the 
mitral systolic murmur in having its maximum of 
intensity at the base of the heart. It is loudest in 
the second intercostal space near the sternum. As 
a rule, it is louder in this intercostal space on the 
right than on the left side ; this rule, however, has 
frequent exceptions. It is transmitted better and 
further upward than downward. It is always heard 
over the carotid artery ; and it is sometimes louder 
over this artery than at the base of the heart. As 
a murmur may be produced within the carotid 
artery, it is desirable to determine, when a systolic 
murmur is heard at the base, whether the carotid 
murmur is a transmitted murmur or not. This point 
is to be settled by comparing the murmur over the 
carotid with the murmur at the base, as regards 
quality and pitch. If the quality and pitch of the 
murmur in the two situations are the same, it is fair 
to consider the murmur in the carotid as not pro- 



220 THE HEART. 

duced within the artery, hut conducted hy the hloocl 
current from the aortic orifice. 

An aortic direct murmur is frequently inorganic. 
It is to he considered as such when it is not associ- 
ated with an aortic regurgitant murmur ; when the 
heart is not enlarged ; when ansemia is shown hy the 
presence of murmurs in the large arteries; and when 
there is the venous hum in the neck — these physical 
evidences of ancemia heing associated with pallor or 
with symptoms pointing to that condition of the 
hlood. Moreover, an inorganic murmur is very 
rarely rough, and it is variable in its occurrence, 
heing at one time present and at another time absent, 
whereas, an organic murmur is, in general, constant. 
Associated with other evidence of ansemia, an aortic 
direct murmur may, nevertheless, be organic, but, 
under the differentiating circumstances just stated, 
the lesion represented by the murmur, if the murmur 
be organic, must be innocuous, so that it is not of 
great practical importance to determine whether the 
murmur be or be not inorganic. 

Like the other organic murmurs, an aortic direct 
murmur varies in different cases in its intensity, 
quality, and pitch. An organic aortic direct mur- 
mur, per se, does not denote always aortic obstruc- 
tion. It may be due simply to roughness of the 
membrane at or above the aortic orifice. 

Aortic Regurgitant Murmur ; Aortic Diastolic Non- 
regurgitant Murmur, — An aortic regurgitant murmur 
occurs with the second sound of the heart, and it is 
the only one of the organic murmurs produced in 
the left side of the heart which has this relation 
with the heart-sounds. It is, therefore, readily 



CARDIAC MURMURS. 221 

enough discriminated from the other murmurs. It 
is almost always heard at the base of the heart, but, 
in some instances, when not appreciable at the base, 
it is heard a little below the base, namely, near the 
sternum on the left side on a level with the fourth 
costal cartilage. In the latter situation it has gene- 
rally its maximum of intensity. It is transmitted 
best in a downward direction, being often heard at 
the apex, and sometimes considerably below this 
point. It is never inorganic. It is usually not 
intense, low in pitch and soft ; but it may be loud, 
high, rough, or musical. 

A short murmur is sometimes produced by the 
retrograde movement of the blood-current within 
the aorta, the aortic valve being sufficient, and re- 
gurgitation not therefore taking place. This mur- 
mur is due to roughening of the lining membrane of 
the aorta by atheroma or calcareous deposit, and it, 
is always preceded by an aortic direct murmur. It 
occurs directly after the systole, and ends with the 
second sound. Although of such brief duration, it 
is distinctly recognizable and distinguished from 
the preceding aortic direct murmur. I have long 
been accustomed to demonstrate this murmur in 
private teaching, and have called it an aortic dias- 
tolic non-regurgitant murmur. It cannot be said 
to have practical importance, inasmuch as the lesion 
giving rise to it is represented by the aortic direct 
murmur which precedes it. 

Coexisting Endocardial Murmurs. — The murmurs 
referable to the left side of the heart, which have 
been considered, are often found in combination; 
two or three may coexist, or all of them may be 

19* 



222 THE HEART. 

present. Moreover, with more or less of these mur- 
murs may be associated murmurs referable to the 
right side of the heart. 

Having become familiar with their relations with 
the heart-sounds, and other points involved in their 
differentiation, it is not difficult to recognize them 
in combination. The mitral murmurs are not infre- 
quently associated. The mitral direct, being pre- 
systolic, ends with the first sound, and the mitral 
systolic or regurgitant begins with this sound; the 
first sound, as it were, divides these two murmurs. 
The murmurs almost invariably differ from each 
other in pitch and quality. The presence of both, in 
fact, assists, rather than obstructs, the recognition of 
each. The aortic direct and the aortic regurgitant 
murmur, also, are often associated. A murmur 
then accompanies the first and the second sound of 
the heart ; the two murmurs follow in the same 
rhythmical order as the heart-sounds. These mur- 
murs, when associated, can only be confounded with 
pericardial friction sounds. 

The combination of the aortic direct and the 
mitral systolic murmur alone offers any difficulty. 
These two murmurs have the same relation with the 
heart-sounds ; they are both systolic. How is it to 
be determined, when a systolic murmur is heard 
both at the base and apex, that either a mitral mur- 
mur is transmitted to the base, or an aortic mur- 
mur is transmitted to the apex ; in other words, 
how is it to be decided whether two murmurs are 
23resent or only one murmur? If these two mur- 
murs coexist, generally the circumstances which 
distinguish each separately can be ascertained. 



GARDIAC MURMURS. 223 

Thus, the aortic murmur is transmitted into the 
carotid artery, and the presence of that murmur is 
then established ; the mitral regurgitant murmur is 
often transmitted laterally around the chest or heard 
at the lower angle of the scapula, and then the pre- 
sence of that murmur is established. But there are 
additional points, namely, the murmur at the base 
and that at the apex generally differ sufficiently in 
pitch or quality to render it evident that there are 
two murmurs ; and generally at a situation in the 
praBCordia between the base and apex, both murmurs 
may be either lost or become notably weakened. 
Attention to these points in most instances divests 
the problem of difficulty. 

Mitral and aortic lesions are often of a char- 
acter to give rise to only one murmur at either of 
these orifices. A mitral direct murmur not infre- 
quently is present without the mitral regurgitant, 
and the reverse of this is frequent. So either an 
aortic direct or an aortic regurgitant murmur may 
exist without the other. 

Tricuspid Direct Murmur, — The lesions which are 
requisite for this murmur very rarely occur at the 
tricuspid orifice ; hence, this murmur is exceedingly 
rare. It is to be distinguished from the mitral direct 
murmur by its localization being, not at the apex, 
but at the right border of the heart. The mitral 
direct and the tricuspid direct murmur may coexist; 
an instance of this kind has fallen under my observa- 
tion. In that instance a presystolic murmur, with 
the characteristic blubbering quality, was heard both 
at the apex and at the right side of the heart. 

Tricuspid Regurgitant Murmur. — This murmur is 



224 THE HEART. 

not of very infrequent occurrence. Tricuspid re- 
gurgitation occurs often when the right ventricle is 
considerably dilated, without the existence of lesions 
of the valve. A tricuspid regurgitation current, 
however, does not invariably give rise to an appreci- 
able murmur. This fact is shown by the occurrence 
of a venous pulse in the neck, due to tricuspid re- 
gurgitation, when no murmur can be heard. 

The tricuspid regurgitant murmur, of course, 
occurs with the first sound, being systolic like the 
mitral regurgitant murmur, and the latter generally 
coexists. It is distinguished from the mitral reeair- 
gitant by its localization at the right inferior margin 
of the heart, and its transmission to the right rather 
than to the left. The coexistence of the mitral and 
the tricuspid regurgitant murmur is determined by 
the differences in pitch and quality between a systolic 
murmur at the apex and at the right margin of the 
heart. A venous pulse synchronous with the first 
sound of the heart, points to tricuspid regurgitation, 
and, although sometimes present without a tricuspid 
regurgitant murmur, when present it is corrobora- 
tive evidence of the latter 

Pulmonic Direct Murmur. — A pulmonic direct 
murmur, if organic, is generally connected with con- 
genital lesions. The pulmonic direct and the aortic 
direct current of blood taking place at the same in- 
stant, the murmurs representing both are, of course, 
systolic. How is the pulmonic to be distinguished 
from the aortic direct murmur? The pulmonic 
murmur is heard in the left second intercostal space 
close to the sternum ; but this is not very distinctive, 
inasmuch as, not infrequently, the aortic murmur is 



CARDIAC MURMURS. 225 

loudest in that situation. The essential point of 
distinction is this: the pulmonic direct murmur is 
not transmitted into the carotid artery, whereas, 
the aortic direct murmur is always thus transmitted. 
If an aortic direct and a pulmonic direct murmur 
coexist, hoth being organic, the combination is to be 
ascertained by finding that the murmur in the 
second intercostal space on the right side differs 
from that on the left side in pitch or quality, suffi- 
ciently to show the presence of two murmurs, the 
one on the right side being transmitted to the caro- 
tid artery. 

An inorganic pulmonic direct murmur is of fre- 
quent occurrence. It is generally associated with 
an inorganic aortic direct murmur, the presence of 
the two murmurs being evidenced by a difference in 
pitch. 

Pulmonic Regurgitant Murmur. — This murmur 
must be exceedingly rare. It occurs, of course, like 
the aortic regurgitant, with the second sound. Its 
presence can only be determined when other signs 
go to show the existence of pulmonic and the 
absence of aortic lesions. This murmur, as well as 
the aortic regurgitant, can never be inorganic, its 
presence being proof of a regurgitant current of 
blood from incompetency of the pulmonic valve. 

Facts of practical importance in relation to the 
endocardial murmurs, are embraced in the following 
statements : — 

The question as to a murmur being organic or 
inorganic, relates chiefly, if not entirely, to the 



226 THE HEART. 

aortic direct and the pulmonic direct murmur, other 
murmurs being almost invariably, if not invariably, 

organic. 

Associated signs and symptoms generally warrant 
a definite conclusion whether an aortic direct or a 
pulmonic direct murmur be, or be not, organic, and 
under the circumstances which render it difficult to 
decide this question positively, a positive decision is 
not of much immediate practical consequence. 

Valvular lesions, whether obstructive, regurgitant, 
or innocuous, are so uniformly represented by mur- 
mur, that, as a rule, absence of lesions may be predi- 
cated on the absence of murmur. 

With a practical knowledge of the different 
organic murmurs, the situation of lesions at either 
of the orifices of the heart, or their existence at two 
or more of these orifices, may be demonstratively 
determined. 

By means of the murmurs, with other signs, it may 
be determined demonstratively whether the lesions 
involve obstruction or regurgitation, or both, or, on 
the other hand, that they are, as regards immediate 
pathological effects, innocuous. 

The murmurs do not afford definite information 
as to the amount of obstruction or regurgitation, in 
other words, as to the pathological importance or 
gravity of lesions when they are not innocuous. !N"o 
positive conclusions on this point of view are to be 
drawn from the intensity of murmurs, their pitch, 
or their quality. As" a rale, murmurs which are 
weak, more than those which are loud, represent 
grave lesions. 



CARDIAC MURMURS. 227 

Pericardial or Friction Murmur. — A pericardial or 
friction murmur is produced by the rubbing together 
of the surfaces of the pericardium in the systolic and 
diastolic movements of the heart. In the vast 
majority of the cases in which this murmur occurs, 
it denotes either the presence of recent lymph which 
renders the surfaces more or less adhesive, or rough- 
ening from lymph which has become dense and 
adherent ; its diagnostic significance, therefore, 
relates almost exclusively to pericarditis. In this 
relation it is of great practical importance. 

This murmur is to be discriminated from the 
endocardial murmurs. The points involved in the 
discrimination are as follows: The murmur is double, 
that is, a murmur accompanies both the ventricular 
systole and diastole. It can, therefore, only be con- 
founded with an aortic direct and an aortic regurgi- 
tant murmur in combination. The quality of the 
murmur is suggestive of rubbing or friction. It is 
sometimes a feeble, grazing sound ; in other instances 
it is loud and quite rough. When rough, the quality 
is expressed by such terms as rasping, grating, creak- 
ing, etc. Although accompanying both sounds of 
the heart, it has not that uniform, fixed relation to 
these sounds which characterizes the aortic direct 
and the aortic regurgitant murmur ; it is not in 
definite accord with the heart-sounds. Moreover, 
in intensity it varies with the successive movements 
of the heart, being louder with some revolutions than 
with others, in this regard differing notably from 
the endocardial murmurs. It is not heard without 
the prsecordia, as a rule, and is often limited to a 
part of the precordial region, whereas, certain of the 



228 THE HEART. 

endocardial murmurs, namely, the mitral regurgi- 
tant and the aortic direct, are often heard at a con- 
siderable distance from the heart. Firm pressure 
with the stethoscope intensifies the murmur. Its 
source seems very near the surface of the chest. In 
this respect it differs notably from endocardial mur- 
murs, the latter appearing to come from a certain 
distance within the chest. This point of distinction 
is very appreciable, especially if, as often happens, a 
friction murmur be associated with an endocardial 
murmur. 



CHAPTER VIII. 

THE PHYSICAL DIAGNOSIS OF DISEASES OF THE 
HEART AND OF THORACIC ANEURISM. 

Enlargement of the heart by hypertrophy and dilatation — Valvular 
lesions, mitral, aortic, tricuspid, and pulmonic — Fatty degeneration 
and softening of the heart — Endocarditis — Pericarditis — Functional 
disorders — Thoracic aneurism. 

The morbid physical conditions incident to the 
different diseases of the heart, and the signs repre- 
senting these conditions, have been considered in 
the preceding chapter. The diseases are now to be 
considered with reference to the assemblage of signs 
on which the physical diagnosis of each is to be 
based. Most of the diseases of the heart may be 
diagnosticated by means of physical signs. A few 
cardiac lesions do not admit of a physical diagnosis, 
and they do not, therefore, claim consideration in this 
work. The following are the affections which will 
form separate headings in this chapter: Enlarge- 
ment of the Heart by Hypertrophy and by Dilatation, 
Valvular Lesions, Fatty Degeneration and Softening 
of the Heart, Endocarditis, Pericarditis, and Func- 
tional Disorders. Having considered these affections, 
the physical diagnosis of thoracic aneurism will be 
the concluding topic. 

Enlargement of the Heart by Hypertrophy and by Dila- 
tation. — Physical exploration to determine the size of 
the heart, has three objects, namely, to determine, 
first, that the size of the heart is normal ; second, 
20 



230 DISEASES OF THE HEAET. 

that the heart is enlarged ; and third, the degree of 
enlargement. These objects are attainable by means 
of percussion and auscultation. 

The heart is of normal size when the apex-beat is 
in its normal situation, that is, in the fifth intercostal 
space, a little within a vertical line jDassing through 
the nipple (the linea mammalis) ; when the superfi- 
cial cardiac space is not enlarged, as shown by per- 
cussion and by auscultation of the voice {vide page 
194) and when percussion shows the lateral borders 
of the heart to be situated normally, namely, on the 
left side a little within the line of the nipple, and on 
the right side a finger's breadth to the right of the 
right margin of the sternum. These points of evi- 
dence warrant a positive conclusion that the heart 
is not enlarged. 

The fact of an enlargement and its degree are 
determinable by an abnormal situation of the apex, 
together with an increase of the superficial cardiac 
space and extension of the lateral boundaries of the 
deep cardiac space especially on the left side. 

In cases of slight or very moderate enlargement, 
the apex is situated a little without the linea mam- 
malis, but not below the 'fifth intercostal space. A 
somewhat greater enlargement lowers the apex to 
the sixth intercostal space, and removes it further 
without the line of the nipple. In greater degrees 
of enlargement the apex is lowered to the seventh, 
eighth, or ninth intercostal space, and generally 
further removed to the left. The lowering of the 
apex and the removal to the left, are not uniformly 
proportionate to each other. As a rule, if the right 
side of the heart be more enlarged than the left, the 



ENLARGEMENT OF THE HEART. 231 

apex is removed without the linea mammalis further 
than when the enlargement of the left side of the 
heart predominates ; and when the latter is the case, 
the apex is lowered out of proportion to its removal 
without that line. The relatively abnormal situa- 
tion downward and to the left, thus, is evidence of 
the enlargement predominating in either the right 
or the left side of the heart. Generally the situa- 
tion of the apex is apparent to the touch and fre- 
quently to the eye. In some instances, however, the 
impulse can neither be seen nor felt. How is its 
situation to be then ascertained? Auscultation 
furnishes a ready and reliable mode of determining 
this point. With the stethoscope the situation in 
which the first sound of the heart has its maximum of 
intensity, corresponds to the situation of the apex. 
This is hardly less definite than the presence of an 
appreciable impulse. 

In determining the fact of enlargement and its 
degree by the abnormal situation of the apex, causes 
of the latter which are extrinsic to the heart are to 
be eliminated. The apex is removed to the left of 
its normal situation by enlargement of the left lobe 
of the liver, abdominal tumors, hydroperitoneum, 
the pregnant uterus, and gastric tympanites. These 
extrinsic conditions are to be excluded or due allow- 
ance made for them. In some cases in which one or 
more of these extrinsic causes of displacement exist, 
the apex is carried into the axillary region. It is to 
be borne in mind that these causes of displacement 
may exist when there is more or less enlargement of 
the heart. All these causes, while they displace the 
apex to the left, do not lower, but tend to raise it 



232 DISEASES OF THE HEAET. 

above its normal situation. On the other hand, an 
aneurismal or other tumor situated above the heart 
may press downward the organ, and in this way the 
apex is more or less lowered. 

The superficial cardiac space is increased in pro- 
portion as the heart is enlarged. The extent of this 
increase is easily determined by percussion and aus- 
cultation. Within this space there is notable dul- 
ness on percussion. The degree of dulness is greater 
than within the superficial cardiac space in health, 
and this degree of dulness is proportionate to the 
greater area in which the heart is uncovered of lung. 
It is sufficiently easy to delineate by percussion on 
the chest the boundary of the anterior border of the 
upper lobe of the left lung, in other words, of the 
oblique line which is the hypothenuse of the right- 
angled triangle representing the superficial cardiac 
space in health and in disease. The area of the 
superficial cardiac space is also not less readily and 
precisely ascertained by auscultation of the voice ; 
the limits of the lung within the pra?corclia are 
denoted by an abrupt cessation or notable diminu- 
tion of the vocal resonance. In females, with large 
mamma?, auscultation is more available for this 
object than percussion. The extent to which the 
superficial cardiac space is enlarged is a good crite- 
rion of the degree of the enlargement of the heart. 

In proportion as the heart is enlarged, the situa- 
tion of the left border is without the linea mammalis. 
Its situation is determined by percussion. Dulness, 
although not great, is sufficiently distinct within 
the deep cardiac space, and the line which denotes 



ENLARGEMENT OF THE HEART. 233 

the left border of the heart is easily delineated on 
the chest. This statement holds true with respect 
to the right border of the heart ; bnt this border, 
even when the enlargement of the heart is great, is 
removed comparatively little to the right of its 
normal situation. By means of percussion the 
boundaries of the pnecordia as enlarged by the in- 
creased size of the heart, may be determined and 
measured. In making this statement it is assumed 
that the lungs are not diseased, and that the chest is 
not deformed. Shrinkage of the upper lobe of the 
left lung may enlarge the superficial cardiac space, 
and cause displacement of the heart. The latter is 
an effect of the presence of pleuritic effusion, and it 
may follow its removal. In cases of deformity from 
spinal curvature, to determine the fact of enlarge- 
ment of the heart, or its degree, is not always an 
easy problem. 

There is a liability to error in localizing the apex 
in some cases of enlargement. Owing to the blunted 
form of the apex, especially when the enlargement 
is chiefly of the right side of the heart, the apex-beat 
may be quite feeble. It is liable to be overlooked, 
and a stronger impulse in the intercostal space above 
the apex, mistaken for the apex-beat. Of course the 
lowest impulse is the apex-beat. Careful palpation, 
and finding by auscultation the spot where the first 
sound has its maximum of intensity, will prevent 
this error. 

Enlargement of the heart, and the degree of en- 
largement having been ascertained, it is to be deter- 
mined whether hypertrophy or dilatation predomi- 

20* 



234 DISEASES OF THE HEART. 

nate. If the enlargement be slight or moderate, it 
may be a question whether hypertrophy or dilatation 
exist alone. As a rule, if either of these two forms 
of enlargement exist without the other, it is hyper- 
trophy, for, with rare exceptions, hypertrophy pre- 
cedes dilatation. If the enlargement be very great, 
as a rule, dilatation predominates, for, the capability 
of hypertrophic increase of size has its limit, and an 
increase of size beyond this limit must be due to 
dilatation. The signs denoting, on the one hand, 
hypertrophy, and, on the other hand, dilatation, 
relate to the impulses of the heart and to the heart- 
sounds. 

With a moderate enlargement, hypertrophy is to 
be inferred from an abnormal force of the apex-beat, 
and an intensification of the characters of the first 
sound over the apex. With a considerable or great 
enlargement, if hypertrophy predominate, the apex- 
beat may be abnormally strong and prolonged, but, 
as already stated, owing to its blunted form, the 
beat is sometimes weak and scarcely appreciable. The 
increased power of the ventricular contractions, 
representing the hypertrophy, is then to be deter- 
mined by impulses in the intercostal spaces above 
the apex. These impulses are sometimes present in 
each intercostal space between the apex and the base ; 
and they are abnormally strong in proportion as 
hypertrophy predominates. Still more marked evi- 
dence of hypertrophy is sometimes obtained when 
the hand is placed over the prsecordia ; a powerful 
heaving movement is felt. The increased power of 
the ventricular contractions may in some cases be in 
this way appreciated somewhat as if the heart were 



VALVULAR LESIONS. 235 

held in the hand. In cases of considerable or great 
enlargement, the intensity of the first sound, over 
the apex, is more or less increased ; it is prolonged 
and its booming quality is more marked than in 
health. ~Not infrequently it is accompanied by a 
metallic ringing sound, or tinnitus. 

Moderate enlargement by dilatation is charac- 
terized by abnormal weakness of the apex-beat, and 
of the first sound over the apex. Cases, however, of 
simple dilatation are rare. If the enlargement be 
considerable or great, and dilatation predominate, all 
the impulses are weak, as compared with the cases 
in which hypertrophy predominates, and the first 
sound over the apex is more or less divested of the 
characters derived from impulsion ; that is, the sound 
is feeble, short, and valvular. These points of dis- 
tinction are marked in proportion as dilatation 
preponderates. 

In the great majority of the cases of enlargement 
of the heart, valvular lesions coexist. These coex- 
isting valvular lesions are represented by endocardial 
murmurs, and they are excluded by the absence of 
the latter. In most of the cases in which enlarge- 
inent exists without valvular lesions, it is associated 
with either pulmonary emphysema or chronic 
Bright's disease. 

Valvular Lesions. 

The physical diagnosis of valvular lesions em- 
braces their localization at the different orifices 
within the heart, and determining their character as 
giving rise to obstruction and regurgitation, or their 
innocuousness in these respects. These objects of 



236 DISEASES OF THE HEART. 

diagnosis involve the endocardial murmurs, and the 
abnormal modifications of the heart-sounds which 
were considered in the preceding chapter. Lesions 
at the different orifices, namely, the mitral, aortic, 
tricuspid, and pulmonic, will be considered sepa- 
rately. 

Mitral Lesions. — The lesions at the mitral orifice 
are represented by the mitral murmurs — the mitral 
direct murmur, the mitral regurgitant, and the 
mitral systolic non-regurgitant or intra-ventricular 
murmur. Mitral obstructive lesions exist whenever 
the mitral direct murmur is present, with an ex- 
ception already stated and explained {vide p. 216), 
namely, this murmur is present in some cases in 
which the mitral valve is intact, aortic lesions, giving 
rise to free regurgitation, existing in these cases. 
These exceptional instances are rare, and I am not 
aware that any have been reported except by myself. 

Mitral regurgitant lesions exist whenever a mitral 
murmur which is truly regurgitant is present. A 
systolic murmur having its maximum of intensity at 
or near the apex, transmitted laterally for a certain 
distance beyond the apex on the left side of the 
chest, and heard on the back near the lower angle of 
the scapula, denotes a regurgitant current ; but a 
systolic murmur limited to a small area around the 
apex, or to the superficial cardiac space, is not proof 
of regurgitation. A truly regurgitant murmur, 
however, may be too feeble to be transmitted beyond 
the apex ; the proof of regurgitation must then be 
based on other evidence associated with the murmur, 
namely, on enlargement of the heart and abnormal 
modifications of the heart-sounds. 



VALVULAR LESIONS. 237 

Mitral obstruction may exist without incompe- 
tency of the mitral valve, as shown by the presence 
of a mitral direct, without a mitral regurgitant, 
murmur. The converse of this is of more frequent 
occurrence, that is, regurgitation may exist without 
obstruction. The absence, however, of a mitral di- 
rect murmur is not positive proof against mitral ob- 
struction, for, as has been seen, the production of a 
characteristic mitral direct murmur, requires the 
obstruction to be caused by an adherence of the 
mitral curtains at their sides, the curtains being 
sufficiently flexible to vibrate with the passage of 
the mitral direct current of blood. Mitral obstruc- 
tion and regurgitation not infrequently coexist, as 
shown by the presence of both the mitral direct and 
the mitral regurgitant murmur. 

The mitral murmurs do not, per se, denote the 
amount of obstruction or regurgitation, or of both 
combined. Information with reference to these 
points may be derived from a comparison of the 
aortic with the pulmonic second sound. The amount 
of obstruction or regurgitation, or both, is great in 
proportion as the aortic sound is weakened. Per 
contra, there can be but little obstruction or reomron- 
tation if the aortic and the pulmonic second sound 
preserve nearly or quite their normal relation to each 
other in respect of intensity. Information may also 
be obtained by analyzing the first sound as heard at 
the apex. In proportion as the function of the 
mitral valve is compromised by lesions, the valvular 
element of the first sound at the apex will be found 
deficient. In some cases the first sound in this 



288 DISEASES OF THE HEART. 

situation has no valvular element, presenting only 
the characters of impulsion. 

Enlargement of the right side of the heart, which 
results from mitral obstructive and regurgitant 
lesions, is a criterion of the amount of obstruction 
and regurgitation taken in connection with the 
length of time in which they have existed. Hyper- 
trophic enlargement of the right ventricle intensifies 
the pulmonic second sound, and allowance must be 
made for this modification in determining, by a 
comparison of the pulmonic and the aortic sound, the 
degree in which the latter is weakened. 

Aortic Lesions. — Lesions are localized at the aortic 
orifice by the aortic murmurs, namely, the aortic 
direct and the aortic regurgitant murmur. Aortic 
obstructive lesions give rise to an aortic direct mur- 
mur; but it must be considered, in the first place, 
that an aortic direct murmur may be inorganic, 
and, in the second place, that, if the murmur be or- 
ganic, it may be* produced by lesions which occasion 
no obstruction and are innocuous. The existence 
of obstructive lesions must be determined by evi- 
dence added to the presence of the murmur. This 
evidence is impairment or suppression of the aortic 
second sound, and enlargement of the left ventricle. 
If the lesions which occasion obstruction are of a 
character to diminish or arrest the movements of 
the aortic valve, the aortic second sound will be 
weakened or lost. If valvular lesions be limited to 
the aortic orifice, the degree of enlargement of the 
heart is a criterion of their pathological importance. 

Regurgitant lesions at the aortic orifice give rise 
to an aortic regurgitant murmur. This murmur, of 



VALVULAE LESIONS. 239 

course, is always proof of regurgitation; but the 
murmur gives no definite information concerning 
the amount of incompetency of the aortic valve. A 
loud murmur maj T he produced by a regurgitant 
stream so small as to be, for the time, insignificant; 
and, on the other hand, a large regurgitant current 
may give rise to a feeble murmur. The extent to 
which the valve is damaged by the lesions, is to be 
determined, first, by the weakness or suppression of 
the aortic sound, and, second, by the degree of 
enlargement of the left ventricle. 

Aortic obstructive and regurgitant lesions are 
often associated. An aortic direct and an aortic 
regurgitant murmur are then both present, with a 
weakened aortic sound or its suppression, and en- 
largement of the left ventricle according to the 
amount of the obstruction and regurgitation, to- 
gether with the length of time during which the 
latter have existed. These effects, and not the 
intensity, or the pitch, or the quality of the mur- 
murs, constitute the criterion of their pathological 
importance. 

Mitral and aortic lesions often coexist, giving rise 
to two, three, or all four of the obstructive and 
regurgitant murmurs in the left side of the heart. 
In addition to the murmurs, in. these cases, the 
effects of the combined lesions are shown in the 
modifications of the heart-sounds, and enlargement 
of both sides of the heart. 

Tricuspid Lesions. — Tricuspid obstructive lesions 
are exceedingly rare. A few instances of the kind 
of obstruction which is represented by a presys- 
tolic or a tricuspid direct murmur have been re- 



240 DISEASES OF THE HEART. 

ported. One instance lias fallen under my obser- 
vation. In this case, as in the other instances 
which have been reported, the tricuspid were asso- 
ciated with mitral lesions ; hence, in localizing an 
obstructive lesion at the tricuspid orifice, the pre- 
sence of the presystolic murmur on each side of the 
heart, that is, the coexistence of mitral and the tri- 
cuspid direct murmur, is to be determined. This 
point has already been considered (vide page 223). 

Tricuspid regurgitation is not uncommon. Gene- 
rally the insufficiency is caused by dilatation of 
the right ventricle occurring as an effect of mitral 
regurgitant or obstructive lesions. Tricuspid regur- 
gitation is not always represented by murmur ; and 
when a tricuspid regurgitant murmur is present, it 
is to be discriminated from a coexisting: mitral re- 
gurgitant murmur. This point has been considered 
(vide page 224). 

Pulmonic Lesions. — As compared with aortic 
lesions, these are of extremely infrequent occurrence, 
and they are generally congenital. Lesions giving 
rise to a pulmonic direct murmur may be localized 
by differentiating this murmur from the aortic 
direct murmur (vide page 224). It is to be considered 
that an inorganic pulmonic direct murmur is not 
infrequent. Pulmonic regurgitant lesions can only 
be diagnosticated by determining that a murmur 
occurring with the second sound of the heart is pro- 
duced at the pulmonic and not at the aortic orifice 
(vide page 225). 

Fatty Degeneration and Softening of the Heart. — 
Fatty degeneration of the heart is not represented by 
any distinctive signs ; but, nevertheless, the physical 



FATTY DEGENERATION AND SOFTENING. 241 

diagnosis, taking into account the clinical history, 
may be quite positive. The signs are those which 
denote persistent muscular weakness of the heart. 
The apex-beat, if appreciable, is feeble. The in- 
tensity of the heart-sounds is diminished, and espe- 
cially the intensity of the first sound. The first 
sound may be even suppressed over the apex, the 
second sound being heard in this situation. The 
characters of the first sound which belong to the 
element of impulsion are especially impaired or lost, 
the sound becoming short and valvular, in these 
respects resembling the second sound. E"ow these 
evidences of weakened muscular power occur when 
the weakness is merely functional, and when the 
heart is enlarged by predominant dilatation. But 
functional weakness is generally transient, and is 
sufficiently explained by the existence of other than 
cardiac disease. Enlargement by dilatation is readily 
determined by physical signs. If the heart be but 
little or not at all enlarged, and pathological condi- 
tions adequate to explain diminished muscular 
power, irrespective of cardiac disease, be excluded, 
at the same time the signs being connected with 
diagnostic symptoms, the existence of fatty degene- 
ration may be determined with much confidence. 

Fatty degeneration may coexist with valvular 
lesions and enlargement of the heart. The physical 
diagnosis of fatty degeneration under these circum- 
stances is not a simple problem. A probable diag- 
nosis may be made when the amount of enlargement 
seems insufficient to account for the signs denoting- 
muscular weakness of the heart, and when symptoms 
21 



242 DISEASES OF THE HEAET. 

belonging to the clinical history point to fatty de- 
generation. 

Softening of the muscular structure of the heart, 
occurring in continued fever and other general dis- 
eases, is denoted by the same signs which are 
embraced in the physical diagnosis of fatty degene- 
ration, the most marked evidence being notable 
weakness, with valvular quality, or suppression, of 
the first sound over the apex of the heart. 

Endocarditis. — The physical diagnosis of endocar- 
ditis relates almost entirely to its occurrence in con- 
nection with articular rheumatism. The diagnostic 
sign is a mitral systolic non-regurgitant murmur 
(vide page 218). The presence of this murmur, how- 
ever, in a case of rheumatism is not positive proof 
of an existing endocarditis, more especially if the 
patient have previously had articular rheumatism, 
because an endocarditis developed in a previous 
attack may have left a permanent murmur. If the 
murmur be a mitral regurgitant murmur and the 
heart be enlarged, it is quite certain that endocar- 
ditis has previously occurred. The positive proof 
is the production of the murmur during an attack 
of rheumatism, when previous examinations, made 
after the commencement of the rheumatic attack, 
had shown that there was no mitral murmur. An 
aortic direct murmur, in cases of rheumatism, is not 
evidence of endocarditis, because in many cases of 
rheumatism this murmur occurs, and is to be re- 
garded as inorganic. 

Endocarditis is probably of frequent occurrence 
as secondary to mitral and aortic valvular lesions ; 



PERICARDITIS. 243 

but, under these circumstances, a physical diagnosis 
is impracticable. 

Pericarditis. — The physical diagnosis of pericar- 
ditis in the first stage, that is, prior to the effusion 
of liquid, is to be based on a pericardial friction 
murmur. Fortunately for diagnosis, this murmur 
is uniformly present. Its characters as contrasted 
with endocardial murmurs have been stated {vide 
page 227). The presence of a pericardial friction 
murmur, in connection with symptoms denoting 
pericarditis, renders the diagnosis quite positive. 
There is, however, one liability to error. In some 
cases of pleurisy or pneumonia with pleuritic in- 
flammation, the movements of the heart occasion a 
rubbing of the outer surface of the pericardium 
against a roughened pleural surface, and in tins way 
a cardiac pleural friction murmur is produced. This 
may be single or double, and when double it simu- 
lates the murmur produced within the pericardial 
sac. It is limited to the border of the heart, and 
is neither accompanied nor followed by pericardial 
effusion. Of course, the error of mistaking a cardiac 
pleural friction murmur for one produced within 
the pericardium, can only occur when pleurisy exists 
either as a primary affection or as secondary to 
pneumonia. 

In the second stage of pericarditis, that is, after 
the effusion of liquid has taken place, the pericardial 
friction murmur often, but not always, disappears. 
The physical diagnosis in this stage is then to be 
based on the signs which show the presence of a 
greater or less quantity of liquid within the peri- 
cardial sac. The signs which denote pericardial 



244 DISEASES OF THE HEART. 

effusion and its amount have been stated {vide page 
206). With a moderate effusion, the apex of the 
heart is raised, and the apex-beat may be felt in the 
fourth intercostal space, and removed to the left of 
its normal situation. With considerable or large 
effusion, the apex-beat is lost, and the sounds of the 
heart are feeble and distant. The first sound loses 
the characters which belong to the element of im- 
pulsion, becoming short and valvular like the second 
sound. 

Increase or diminution of liquid, in the second 
stage of pericarditis, is readily determined by signs 
obtained by percussion and auscultation. When the 
quantity is much diminished, the friction murmur, 
if it have been suppressed, returns, and persists until 
the pericardial surfaces become agglutinated. Not 
infrequently, by auscultating when the body of the 
patient is inclined forward, a friction murmur may 
be heard notwithstanding the pericardial sac con- 
tains a large quantity of liquid. 

In cases of chronic pericarditis with very large 
effusion, dilatation of the pericardial sac is shown 
by signs obtained by percussion and auscultation. 
There is no apex impulse ; the heart-sounds are 
feeble and distant, the first sound being short and 
valvular, and the praecordia may be notably projecting. 

A malignant morbid growth filling the pericardial 
sac and inclosing within it the heart, may give rise 
to all the signs of pericardial effusion. A case of 
this kind, in a young subject, has fallen under my 
observation. 

With reference to diagnosis, the etiological rela- 
tions of pericarditis should be kept in mind. These 



FUNCTIONAL DISORDERS. 245 

are, acute articular rheumatism, Bright's disease, 
and either pleurisy or pneumonia. It rarely occurs 
in other connections, and, as an idiopathic affection, 
it is extremely rare. 

The presence of air and liquid within the peri- 
cardial sac gives rise to loud splashing sounds which, 
occurring when respiration is suspended, and when 
pneumo-hydrothorax is excluded, are at once diag- 
nostic of pneumo-hydropericardium. 

Functional Disorders. — Of the varied forms of 
functional disorder of the heart, some are rare, and 
others are of frequent occurrence. A rare form is 
persistent frequency of the heart's action, the pulse 
being from 100 to 120 or more per minute, for weeks, 
months, and even years. This form of disorder ex- 
ists in the affection known as exophthalmic goitre, 
Graves' or Basedow's disease. It occurs, also, with- 
out being associated with either prominence of the 
eyes or enlargement of the thyroid body. In a rare 
form the opposite of this, the action of the heart is 
abnormally infrequent, the pulse falling to 50,40,30 
or less, per minute, the infrequency not being an 
idiosyncrasy either congenital or acquired, and con- 
tinuing for a limited period. The occurrence with 
every alternate revolution of the -heart of a ventricu- 
lar systole so feeble as not to be represented by a 
radial pulse, is another rare form ; and another is a 
want of synchronism in the contractions of the two 
ventricles, giving rise to reduplication of the heart- 
sounds. In the more common forms, the disorder 
occurs in paroxysms which are variable in duration 
and in the frequency of their occurrence, the heart, 
in the paroxysms, beating irregularly, and often with 

21* 



246 DISEASES OF THE HEART. 

intermissions, the action in some instances being 
violent, and in other instances feeble or fluttering. 
These common forms are embraced under the name 
palpitation. 

As regards the physical diagnosis, all the forms of 
disorder are in the same category ; in all, the func- 
tional character of the affection is determined by 
exclusion, inflammatory affections and lesions being 
excluded by the absence of their diagnostic signs. 
In whatever way the action of the heart is disturbed, 
however great may be the disturbance, and let it be 
attended with ever so much distress or anxiety, if 
physical exploration furnish no evidence of endo- 
carditis, pericarditis, valvular lesions, enlargement 
of the heart, fatty degeneration, or heart-clot, the 
affection is to be considered as functional. If purely 
functional, the affection is unattended by any danger, 
and is generally remediable, at least in the common 
forms. Hence the very great importance of a posi- 
tive diagnosis. 

In one point of view, the physical diagnosis in 
functional disorders may be said to rest, not on nega- 
tive, but on }30sitive evidence. Percussion and aus- 
cultation afford the means, not only of excluding 
inflammatory affections and lesions, but of demon- 
strating the fact that the organ is sound, at least as 
regards freedom from ordinary lesions. That its size 
is normal, is shown by the situation of the apex-beat ; 
by ascertaining the lateral boundaries of the prse- 
corclia and the area of the superficial cardiac space. 
That the valves are unaffected, is shown by the nor- 
mal characters of the heart-sounds. These positive 
facts, taken in connection with the absence of 



FUNCTIONAL DISORDEES. 247 

morbid signs, render the diagnosis quite certain. 
Moreover, the evidence, positive and negative, is 
readily and quickly obtained. Indeed, the time re- 
quired for reaching a conclusion is so brief, that it 
is often politic to prolong unnecessarily the examina- 
tion in order that a positive assurance of the sound- 
ness of the organ may have in the mind of the patient 
the weight which is desirable in order to secure 
relief from anxiety and apprehension. 

Functional disorders are not infrequently associated 
with lesions with which they have no essential patho- 
logical connection. A patient with lesions which 
are either innocuous or attended with little, if any, 
inconvenience, may sutler from disturbance of the 
action of the heart produced by causes which are 
wholly independent of the lesions. There is a 
liability, in these cases, to the error of attributing 
the disorders to the lesions, and thus forming an 
exaggerated estimate of the importance of the latter. 
To decide how much of the disturbed action of the 
heart is due to a superadded functional affection, is 
not as easy as to determine that lesions do not exist. 
The decision must be based on the character, degree, 
or extent of the lesions, as evidenced by the physical 
signs. In this connection may be stated a practical 
maxim, which it is well to bear in mind, whether 
functional disorders exist or not, namely, valvular 
lesions rarely give rise to much inconvenience until 
they have led to enlargement of the heart ; and en- 
largement, either with or without valvular lesions, 
as a rule, does not lead to the serious effects which 
are characteristic of cardiac disease, so long as the en- 
largement is due to hypertrophy and not to dilatation. 



248 DISEASES OF THE HEART. 



Thoracic Aneurism. 

The physical conditions incident to thoracic aneu- 
rism, which are concerned in the production of signs, 
are, the presence of a tumor within the chest, of 
variable size, formed by the aneurismal sac ; the 
passage of blood into the sac with each ventricular 
systole, and the expulsion of blood in the diastole by 
the recoil of the coats of the aneurism ; the size of 
the opening into the sac as affecting the quantity of 
blood which it receives with each systole ; the 
quantity of stratified fibrin which the sac contains ; 
the point of connection with the aorta of the aneu- 
rismal tumor, and the direction from this point in 
which the tumor extends, together with its relations 
to the lungs, the trachea, and the primary bronchi. 

With reference to diagnosis, it is well to bear in 
mind that, in the great majority of cases, an aortic 
aneurism is connected with either the ascending 
portion, or the junction of the ascending and the 
transverse portion of the arch, and that the tumor 
generally extends to the right in a lateral or antero- 
lateral direction. The physical diagnosis is more 
easily made when the aneurismal tumor is thus con- 
nected. The signs are less available if the aneurism 
arise from the transverse or descending aorta, and 
especially if the tumor extends in a direction down- 
ward or backward. 

An aneurismal tumor which has made its way 
through the walls of the chest, or which, without 
perforation, causes a circumscribed bulging, obvious 
to the eye and touch, presents the following diag- 



THORACIC ANEURISM. 249 

nostic signs: An impulse is seen and felt wliicli is 
synchronous with the ventricular systole. The 
force of the impulse is variable, depending, aside 
from the force with which the left ventricle con- 
tracts, upon the size of the orifice between the sac 
and the artery, and the quantity of fibrin which the 
sac contains. A vibration or thrill with each im- 
pulse is sometimes a marked sign, but is often 
wanting. Frequently, but by no means constantly, 
a systolic murmur is heard over the tumor, and 
there may be also a diastolic murmur produced by 
the passage of blood from the sac. The heart-sounds 
over the tumor are more or less intense. There is 
notable dulness on percussion over an area corre- 
sponding to the space within the chest which the 
tumor occupies. If the tumor be of considerable 
size, it may produce condensation of lung around 
it ; the area of dulness on percussion will be in this 
way extended beyond the limits of the tumor. 
Under these circumstances, bronchial respiration 
and bronchophony may be produced. If the aneu- 
rismal sac be beneath the integument, there may be 
to the touch a sense of fluctuation. 

With the foregoing signs, the physical diagnosis 
scarcely admits of doubt. Some of the signs may 
be produced by a tumor, not aneurismal, which is so 
situated as to receive and conduct the aortic im- 
pulse. The chances of a tumor being so situated as 
to simulate the signs of an aneurism are very few. 
I have met with a case of empyema in which per- 
foration of the chest took place in the second inter- 
costal space on the right side of the sternum, giving 
rise in this situation to a fluctuating tumor which 



250 DISEASES OF THE HEART. 

had a strong pulsation. On a superficial examina- 
tion the case seemed clearly one of aneurism; but 
an examination of the chest showed the right pleural 
cavity to he filled with liquid, and a puncture in 
the axillary region gave exit to a large quantity of 
pus, the pulsating tumor disappearing after a certain 
quantity of the purulent liquid had escaped. 

"When, from its small size or its situation, an 
aneurismal tumor does not come into contact with 
the thoracic wall, and when it is situated beneath 
the sternum, signs obtained by palpation and in- 
spection being absent, the physical diagnosis is less 
easy. Important signs are, dulness within a circum- 
scribed space situated in the course of the aorta ; an 
abnormal transmission of the heart-sounds within 
this space, and the presence of murmurs. These 
signs are not always available, and when present 
they are not sufficient for a positive diagnosis. 
Other physical evidence and the presence of certain 
symptoms render the existence of aneurism highly 
probable either with or without the foregoing signs. 
If an aneurismal tumor press upon the trachea, it 
occasions a tracheal sound, or stridor, together with 
weakness of the respiratory murmur on both sides 
of the chest. If the tumor press upon a primary 
bronchus, it occasions diminished or suppressed res- 
piratory murmur on one side, and increased res- 
piratory murmur on the other side of the chest. 
These physical signs should always lead to a suspi- 
cion of aneurism in a person forty years of age. 
Symptoms which should excite this suspicion and 
lead to careful physical exploration for the physical 
signs of aneurism, are dyspnoea from spasm of the 



THORACIC ANEURISM. 251 

glottis, and aphonia or impairment of the voice 
without evidence of laryngitis, these symptoms 
denoting either excitation or pressure of the recur- 
rent laryngeal nerve ; dysphagia from obstruction 
of the oesophagus ; congestion of the face, neck, and 
upper extremities from obstruction of the vena cava 
or the venae innominatse; inequality of the radial, 
carotid and subclavian pulsation on the two sides, 
or the absence of pjulsation on one side, and con- 
traction of one of the pupils. These symptoms not 
only render probable the existence of aneurism, but 
indicate its situation as regards the aorta and the 
direction in which the aneurismal tumor extends. 

An aneurism may be suspected when, owing to 
shrinkage of the lung, or deformity of the chest, 
either the aorta or the pulmonary artery, just above 
the heart, is removed laterally from its normal situa- 
tion and brought into contact with the walls of the 
chest in the second intercostal space so as to give 
rise to an appreciable impulse. A murmur may 
also be present at the point of impulse. An error 
of diagnosis under these circumstances is avoided 
by finding an adequate explanation of the signs just 
noted, and by the absence of other signs and of 
symptoms which are diagnostic of aneurism. 

In conclusion, an aortic murmur, however intense 
or rough, is never evidence of aortic aneurism. 



INDEX 



ADVENTITIOUS respiratory 
sounds or rales, 112 
JEgophony, 131 

Amphoric resonance on percussion, 
65 
respiration, 106 
Aneurism, thoracic, 248 
Aortic direct murmur, 219 
lesions, diagnosis of, 238 
regurgitant murmur, 220 
Apex-beat of heart, modification of, 

202 
Apoplexy, pulmonary, 173 
Artery, pulmonic, and aorta, rela- 
tion of, to walls of chest, 194 
Asthma, 151 

Auscultation, definition of, 14 
in disease, 90 
in health, 69 

mediate and immediate, 70 
rules in practice of, 72 



BRONCHIAL rales, dry, 118 
moist, 113 
respiration, 97 
whisper, increased, 135 
Bronchitis seated in large bronchial 
tubes, 146 
in small bronchial tubes 
(capillary), 148 
Broncho-cavernous respiration, 105 
Bronchophony, 129 
whispering, 131 
Broncho-vesicular respiration, 99 



CARCINOMA of lung, 177 
Cardiac space, superficial and 
deep, 192 
Cavernous rale, 123 
respiration, 103 
Chest, anatomy and physiology of, 
16 
regional divisions of, 35 
Cirrhosis of lung, 188 

22 



Conditions, morbid physical, inci- 
dent to different diseases 
of the respiratory sys- 
tem, 20 
summary of, 26 
physical, of the heart in disease, 
200 
in health, 192 
represented by amphoric reso- 
nance, 65 
by cracked -metal reso- 
nance, 67 
by dulness, 61 
by flatness on percussion, 

59 
by tympanitic resonance, 

63 
by vesiculotympanitic re- 
sonance, 64 
Coughing, signs obtained by, 141 
Cracked-metal resonance on percus- 
sion, 67 
Crepitant rale, 120 



DIAPHRAGMATIC hernia, 189 
Diseases of the respiratory 
system, physical conditions 
incident to, 20 
Dulness on percussion, 61 



ECHO, amphoric, 137 
Emphysema, pulmonary or 
vesicular, 153 
Empyema, 158 

Endocarditis, diagnosis of, 242 
Exocardial murmur, 227 
Expiratory sound, prolonged, 108 
Exploration, physical, different 
methods of, 13 



V 



LATNESS on percussion, 59 
Fremitus, normal, vocal, S2 
in different regions, 85 



254 



INDEX, 



Friction murmur, pericardial, 227 
pleuritic, rales, 124 



G 



ANGRENE, pulmonary, 175 



HEART, abnormal impulses of, 
202 
diagnosis of diseases of, 229 
enlargement of, 200 
fatty degeneration and soften- 
ing of, 240 
first sound of, intensified, 207 

weakened, 207 
functional disorders of, 245 
murmurs of, 212 
physical conditions of, in dis- 
ease, 200 
in health, 192 
diagnosis of diseases of, 229 
second sound, aortic, weakened, 
208 
pulmonic, weakened, 
209 
sounds of, 195 
valvular lesions of, 204 
diagnosis of, 235 
Heart-sounds, abnormal modifica- 
tions of, 206 
reduplication of, 210 
Hemorrhagic infarctus, 173 
Hernia, diaphragmatic, 189 
Hydrothorax, 164 



INDETERMINATE rales, 128 
Infarctus, hemorrhagic, 173 
Inspiratory sound, shortened, 107 
Intensity of normal and abnormal 

sounds, differences of, 28 
Interrupted respiration, 110 



LARYNGEAL and tracheal respi- 
ration, 74 
rales, 112 
Larynx and trachea, affections of, 

144 
Lesions, valvular, of heart, 204 

diagnosis of, 236 
Lobular pneumonia, 148 
Lobules, pulmonary, collapse of, 148 



METALLIC tinkling, 126, 140 
Mitral lesions, diagnosis of, 236 



Murmur, aortic direct, 219 

diastolic or non-regurgi- 

tant, 220 
regurgitant, 220 
cardiac, 212 
mitral direct, 215 

regurgitant, 217 
normal vesicular, 76 
pericardial or friction, 227 
pulmonic direct, 224 
regurgitant, 225 
systolic non-regurgitant or 

intra-ventricular, 217 
tricuspid direct, 223 
regurgitant, 223 
vesicular, diminished, 92 
increased, 91 
Murmurs, endocardial coexisting. 
221 
facts of importance relating to, 
225 



(E 



DEMA, pulmonary, 175 



PECTORILOQUY, 136 
Percussion, definition of, 14 

in health, 40 

in disease, 58 

modes of performing, 40 

objects of, 41 

respiratory, 54 

rules in practice of, 54 

signs of disease furnished by, 
58 

source of resistance in, 68 
Pericardial or friction murmur, 
227 

sac, liquid within, 205 

surfaces, roughness of, 205 
Pericarditis, diagnosis of, 243 
Phthisis, 181 

fibroid, 188 
Pitch of normal and abnormal 

sounds, 30 
Pleural rales, 124 
Pleurisy, acute and chronic, 158 
Pneumonia, acute lobar, 167 

circumscribed, 173 

embolic, 173 

interstitial, 188 

lobular, 14S 
Pneumo-hydrothorax, 165 
Pneumothorax, 165 
Prsecordia, 192 



INDEX 



255 



Pulmonary apoplexy, 173 

gangrene, 175 

oedema, 175 
Pulmonic direct murmur, 224 

lesions, diagnosis of, 240 

regurgitant murmur, 225 



QUALITY of normal and abnor- 
mal sounds, 30 
terms denoting, 32 



RALE, cavernous or gurgling, 123 
crepitant or vesicular, 120 
indeterminate, 128 
metallic tinkling, 126 
splashing or succussion, 127 
Rales, 112 

bubbling or subcrepitant, 115 
dry bronchial, 118 
laryngeal and tracheal, 112 
moist bronchial, 113 
pleural or friction, 124 
Regions, division of chest into, 35 
sections of chest corresponding 
to, 37 
Resonance, amphoric, 65 
cracked- metal, 67 
diminished, or dulness, 61 
in different regions, 85 
normal, vesicular, on percus- 
sion, 41 
vocal, over larynx and 
trachea, 81 
on percussion, absence of, or 

flatness, 58 
over chest, 82 
tympanitic, 63 
variations in different regions 

of chest, 45 
vesiculo-tympanitic, 64 
Respiration, abnormal modifica- 
tions of, 91 
amphoric, 106 
bronchial or tubular, 97 
broncho-cavernous, 105 
broncho-vesicular, 99 
cavernous, 103 
diminished, 92 
in different regions, 78 
interrupted, 1 10 
normal, laryngeal, and tra- 
cheal, 74 
vesicular, murmur of, 76 
suppressed, 95 



Respiration — 

vesicular murmur of, in- 
creased, 91 



SIGNS, arrangement of, 111 
by percussion in disease, 58 

in health, 40 
healthy and morbid, distinc- 
tive characters of, 27 
obtained by coughing, 141 
physical, definition of, 14 
respiratory, in disease, 90 

in health, 74 
significance of, 34 
vocal, in health, 81 
of disease, 129 
Sounds, differences of intensity in, 
28 
in pitch, 29 
in quality, 30 
normal and abnormal, 14 
Splashing or succussion sounds, 

127 
Stethoscope, advantages of, 70 
binaural, 71 



TRICUSPID, direct murmur, 223 
lesions, diagnosis of, 239 
regurgitant murmur, 223 
Tuberculosis, acute, 180 
Tumor within the chest, 177 
Tussive signs, 141 
Tympanitic resonance on percus- 
sion, 63 



TTESICULO-TYMPANITIC reS o- 
V nance on percussion, 64 
Vocal fremitus, diminished or sup- 
pressed, 140 
increased, 134 
resonance, diminished and sup- 
pressed, 138 
increased, 132 
signs of disease, 129 
Voice, amphoric, 137 



WHISPER, bronchial, increased, 
135 
cavernous, 136 
in different regions, 88 
normal bronchial, 87 
Whispering pectoriloquy, 137 



CATALOGUE OF BOOKS 

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MEDICAL NEWS AND LIBRARY, monthly, 384 large | . an ™ m > 
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ASHTON (T. J.) ON THE DISEASES, INJURIES, AND MALFOR- 
MATIONS OF THE RECTUM AND ANUS. With remarks on 
Habitual Constipation. Second American from the fourth London 
edition, with illustrations. 1 vol. 8vo. of about 300 pp. Cloth, $3 25. 

ASHWELL (SAMUEL). A PRACTICAL TREATISE ON THE DIS- 
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ASHHURST (JOHN, Jr.) THE PRINCIPLES AND PRACTICE OF 
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wood-cuts. Cloth, $6 50; leather, $7 50. 

ATTFIELD (JOHN). CHEMISTRY; GENERAL, MEDICAL, AND 
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1 vol. 12mo. Cloth, $2 75 ; leather, $3 25. 

ANDERSON (McCALL). ON THE TREATMENT OF DISEASES 
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BLOXAM (C. L.) CHEMISTRY, INORGANIC AND ORGANIC. 
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BRINTON (WILLIAM). LECTURES ON THE DISEASES OF THE 
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BRTJNTON (T. LAUDER). A MANUAL OF MATERIA MEDIC A 
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AND CULLERIER'S ATLAS OF VENEREAL. See "Cttlle- 

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BARLOW (GEORGE H.) A MANUAL OF THE PRACTICE OF 
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BAIRD (ROBERT). IMPRESSIONS AND EXPERIENCES OF THE 
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BRYANT (THOMAS). THE PRACTICE OF SURGERY. In one 
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BLANDFORD (G. FIELDING). INSANITY AND ITS TREATMENT. 
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BRISTOWE (JOHN SYER). A MANUAL OF THE PRACTICE OP 
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BELLAMY'S MANUAL OF SURGICAL ANATOMY. With numerous 
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BOWMAN (JOHN E.) A PRACTICAL HAND-BOOK OF MEDICAL 
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INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUD- 
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CARTER (R BRUDENELL). A PRACTICAL TREATISE ON DIS- 
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CHAMBERS (T. K.) A MANUAL OF DIET IN HEALTH AND 
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$2 75. {Just issued.) 

RESTORATIVE MEDICINE. An Harveian Annual Oration 

delivered at the Royal College of Physicians, London, June 21, 1871. 
In one small 12mo. volume. Cloth, $1 00. 

COOPER (B. B.) LECTURES ON THE PRINCIPLES AND PRACTICE 
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pARPENTER (WM. B.) PRINCIPLES OF HUMAN PHYSIOLOGY, 
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$5 50 ; leather, raised bands, $6 50. 

PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN 

HEALTH AND DISEASE. New edition, with a Preface by D. F. 
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CHRISTISON (ROBERT). DISPENSATORY OR COMMENTARY ON 
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CHURCHILL (FLEETWOOD). ON THE THEORY AND PRACTICE 
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ESSAYS ON THE PUERPERAL FEVER, AND OTHER DIS- 
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450 pages. Cloth, $2 50. 

CONDIE (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS- 
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one large octavo volume of nearly 800 pages. Cloth, $5 25 ; lea- 
ther, $6 25. 
0ULLERIER (A.) AN ATLAS OF VENEREAL DISEASES. Trans- 
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Same work, in five parts, paper covers, for mailing, $3 per part. 

CYCLOPEDIA OF PRACTICAL MEDICINE. By Dunglison, Forbes, 
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CAMPBELL'S LIVES OF LORDS KENYON, ELLENBOROUGH, AND 
TENTERDEN. Being the third volume of " Campbell's Lives of 
the Chief Justices of England." In one crown octavo vol. Cloth, $2. 



D 



ALTON (J. C.) A TREATISE ON HUMAN PHYSIOLOGY. Sixth 
edition, thoroughly revised, and greatly enlarged and improved, with 
316 illustrations. In one very handsome 8vo. vol. of 830 pp. 
Cloth, $5 50 ; leather, $6 50. {Just issued.) 

DAVIS (F. H.) LECTURES ON CLINICAL MEDICINE. Second 
edition, revised and enlarged. In one 12mo. vol. Cloth, $1 75. 
DON QUIXOTE DE LA MANCHA. Illustrated edition. In two hand- 
some vols, crown 8vo. Cloth, $2 50 ; half morocco. $3 70. 

DEWEES (W. P.) A TREATISE ON THE DISEASES OF FEMALES. 
With illustrations. In one 8vo. vol. of 536 pages. Cloth, $3. 

A TREATISE ON THE PHYSICAL AND MEDICAL TREAT- 



MENT OF CHILDREN. In one 8vo. vol. of 548 pages. Cloth, $2 80. 

DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF MO 
DERN SURGERY. A revised American, from the eighth London 
edition. Illustrated with 432 wood engravings. In one 8vo. a t o1. 
of nearly 700 pages. Cloth, $4; leather, $5. 

DITNGLISON (ROBLEY) MEDICAL LEXICON ; a Dictionary of 
Medical Science. Containing a concise explanation of the various 
subjects and terms of Anatomy, Physiology, Pathology, Hygiene, 
Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral 
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and other Synonymes. In one very large royal 8vo. vol. New edi- 
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HUMAN PHYSIOLOGY. Eighth edition, thoroughly revised. 

In two large 8vo. vols, of about 1500 pp., with 532 illus. Cloth, $7. 
NEW REMEDIES, WITH FORMULA FOR THEIR PREPARA- 



TION AND ADMINISTRATION. Seventh edition. In one very 
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DE LA BECHE'S GEOLOGICAL OBSERVER. In one large 8vo. vol. 
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DANA (JOIES D.) THE STRUCTURE AND CLASSIFICATION OF 
ZOOPHYTES. With illustrations on wood. In one imperial 4to. vol. 
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ELLIS (BENJAMIN). THE MEDICAL FORMULARY. Being a 
collection of prescriptions derived from the writings and practice of 
the most eminent physicians of America and Europe. Twelfth edi- 
tion, carefully revised, by A. H. Smith, M. D. In one 8vo. volume 
of 374 pages. Cloth, $3. 

ERICHSEN (JOHN). THE SCIENCE AND ART OF SURGERY. 
A new and improved American, from the sixth enlarged and re- 
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ENCYCLOPEDIA OF GEOGRAPHY. In three large 8vo. vols. Illus- 
trated with 83 maps and about 1100 wood-cuts. Cloth, $5. 
FENWICK (SAMUEL). THE STUDENTS' GUIDE TO MEDICAL 
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$2 25. {Just issued.) 



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FLETCHER'S NOTES FROM NINEVEH, AND TRAVELS IN MESO- 
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F 



DX ON DISEASES OF THE STOMACH. From the third London edi- 
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FLINT (A.USTIK). A TREATISE ON THE PRINCIPLES AND 
PRACTICE OF MEDICINE. Fourth edition, thoroughly revised 
and enlarged. In one large 8vo. volume of 1070 pages. Cloth, $6 ; 
leather, raised bands, $7. (Just issued.) 

. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
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AFFECTING THE RESPIRATORY ORGANS. Second and revised 
edition. One 8vo. vol. of 595 pages. Cloth, $4 50. 

A PRACTICAL TREATISE ON THE DIAGNOSIS AND TREAT- 

MENT OF DISEASES OF THE HEART. Second edition, enlarged. 
In one neat 8vo. vol. of over 500 pages, $4 00. 

ON PHTHISIS : ITS MORBID ANATOMY, ETIOLOGY, etc., 

in a series of Clinical Lectures. A new work. In one handsome 8vo. 
volume. Cloth, $3 50. (Just issued.) 

MEDICAL ESSAYS. In one neat 12mo. volume. Cloth, $1 38. 



FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEMISTRY. 
From the tenth enlarged English edition. In one royal 12mo. vol. of 
857 pages, with 197 illustrations. Cloth, $2 75 ; leather, $3 25. 

ftJLLER (HENRY). ON DISEASES OF THE LUNGS AND AIR 
PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and 
Treatment. From the second English edition. In one 8vo. vol. 
of about 500 pages. Cloth, $3 50. 

GALLOWAY (ROBERT). A MANUAL OF QUALITATIVE AN- 
ALYSIS. From the fifth English edition. In one 12mo. vol. Cloth, 

$2 50. (Lately published.) 

LUGE (GOTTLIEB). ATLAS OF PATHOLOGICAL HISTOLOGY, 
Translated by Joseph Leidy, M.D., Professor of Anatomy in the 
University of Pennsylvania, &c. In one vol. imperial quarto, with 
320 copperplate figures, plain and colored. Cloth, $4. 

REEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY AND 
MORBID ANATOMY. Second Amer., from the third Lond. Ed. 
In one handsome 8vo. vol., with numerous illustrations. Cloth, 
$2 75. (Just ready ) 

RAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. 
A new American, from the fifth and enlarged London edition. In one 
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GRIFFITH (ROBERT E.) A UNIVERSAL FORMULARY, CON- 
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a ROSS (SAMUEL D.) A SYSTEM OF SURGERY, PATHOLOGICAL, 
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by 1403 engravings. Fifth edition, revised and improved. In two 
large imperial 8vo. vols, of over 2200 pages, strongly bound in 
leather, raised bands, $15. (Lately issued.) 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 

AIR PASSAGES. In one 8vo. vol. of 468 pages. Cloth, $2 75. 



G 



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GIBSON'S INSTITUTES AND PRACTICE OE SURGERY. In two 8vo. 
vols, of about 1000 pages, leather, $6 50. 

HUDSON (A.) LECTURES ON THE STUDY OF EEYER. 1 vol. 
8vo., 316 pages. Cloth, $2 50. 

HEATH (CHRISTOPHER). PRACTICAL ANATOMY ; A MANUAL 
OF DISSECTIONS. With additions, by W. W. Keen, M. D. In 1 
volume; with 247 illustrations. Cloth, $3 50; leather, $4. 

HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES 
AND PRACTICE OF MEDICINE. Fourth and revised edition. 
In one 12mo. vol. Cloth, $263; halfbound, $2 88. {Lately issued ) 



— CONSPECTUS OF THE MEDICAL SCIENCES. Comprising 
Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- 
tice of Medicine, Surgery, and Obstetrics. Second Edition. In one 
royal 12mo. volume of over 1000 pages, with 477 illustrations. 
Strongly bound in leather, $5 00; cloth, $4 25. (Lately issued.) 

— A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 



H 



neat royal 12mo. volume, with many illustrations. Cloth, $1 75. 

HAMILTON (FRANK H.) A PRACTICAL TREATISE ON FRAC- 
TURES AND DISLOCATIONS. Fifth edition, carefully revised. 
In one handsome 8vo. vol. of 830 pages, with 344 illustrations. Cloth, 
$5 75 ; leather, $6 75. {Now ready.) 

OLMES (TIMOTHY). SURGERY, ITS PRINCIPLES AND PRAC 
TICE. In one handsome 8vo. volume of 1000 pages, with 411 illus- 
trations. Cloth, $6; leather, with raised bands, $7. {Just ready.) 

HOBLYN (RICHARD D.) A DICTIONARY OF THE TERMS USED 
IN MEDICINE AND THE COLLATERAL SCIENCES. In one 
12mo. volume, of over 500 double-columned pages. Cloth, $1 50; 
leather, $2. 

HODGE (HUGH L.) ON DISEASES PECULIAR TO WOMEN, IN- 
CLUDING DISPLACEMENTS OF THE UTERUS. Second and 
revised edition. In one 8vo. volume. Cloth, $4 50. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
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original photographs, and with numerous wood-cuts. In one large 
quarto vol. of 550 double-columned pages. Strongly bound in cloth 
$14. 

HOLLAND (SIR HENRY). MEDICAL NOTES AND REFLECTIONS. 
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Cloth, $3 50. 

3DGES (RICHARD M.) PRACTICAL DISSECTIONS. Second edi- 
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HUGHES. SCRIPTURE GEOGRAPHY AND HISTORY, with 12 
colored maps. In 1 vol. 12mo. Cloth, $1. 

TX3RNER (WILLIAM E.) SPECIAL ANATOMY AND HISTOLOGY. 
■"■ Eighth edition, revised and modified. In two large 8vo. vols, of over 
1000 pages, containing 300 wood-cuts. Cloth, $6. 



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TJILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DIS 
J-L ORDERS. In one 8vo. volume of 467 pages. Cloth, $3 25. 

TTILLIER (THOMAS). HAND-BOOK OF SKIN DISEASES. Second 
J--L Edition. In one neat ro.ral 12mo. volume of about 300 pp., with two 
plates. Cloth, $2 25. 



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HALL (MRS. M.) LIVES OF THE QUEENS OF ENGLAND BEFORE 
THE NORMAN CONQUEST. In one handsome 8vo. vol. Cloth, 
$2 25; crimson cloth, $2 50; half morocco, $3. 

TONES (C. HANDFIELD). CLINICAL OBSERVATIONS ON FUNC- 
« TIONAL NERVOUS DISORDERS. Second American Edition. In 
one 8vo. vol. of 348 pages. Cloth, $3 25. 

K TREES (WILLIAM SENHOUSE). A MANUAL OF PHYSIOLOGY. 
A new American, from the eighth London edition. One vol., with 
many illus., 12mo. Cloth, $3 25; leather, $3 75. {Lately issued.) 

NAPP (F.) TECHNOLOGY ; OR CHEMISTRY, APPLIED TO THE 
ARTS AND TO MANUFACTURES, with American additions, by 
Prof. Walter R. Johnson. In two 8vo. vols., with 500 ill. Cloth, $6. 

KENNEDY'S MEMOIRS OF THE LIFE OF WILLIAM WIRT. In 
two vols. 12mo. Cloth, $2. 

LEA (HENRY C.) SUPERSTITION AND FORCE ; ESSAYS ON THE 
WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, 
AND TORTURE. Second edition, revised. In one handsome royal 
12mo. vol., $2 75. 

STUDIES IN CHURCH HISTORY. The Rise of the Temporal 

Power — Benefit of Clergy — Excommunication. In one handsome 
12mo. vol. of 515 pp. Cloth, $2 75. 
AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY 



IN THE CHRISTIAN CHURCH. In one handsome octavo volume 
of 602 pages. Cloth, $3 75. 

A ROCHE (R.) YELLOW FEVER. In two 8vo. vols, of nearly 1500 

• pages. Cloth, $7. 

PNEUMONIA. In one 8vo. vol. of 500 pages. Cloth, $3. 



LINCOLN (D. F.) ELECTRO-THERAPEUTICS. A Condensed Man- 
ual of Medical Electricity. In one neat royal 12mo. volume, with 
illustrations. Cloth, $1 50. {Just issued.) 

LEISHMAN (WILLIAM). A SYSTEM OF MIDWIFERY. Includ- 
ing the Diseases of Pregnancy and the Puerperal State. Second 
American, from the Second English Edition. With additions, by 
J. S. Parry, M.D. In one very handsome 8vo. vol. of 800 pages and 
200 illustrations. Cloth, $5 ; leather, $6. {Just issued.) 

LAURENCE (J. Z.) *\ND MOON (ROBERT C.) A HANDY-BOOK 
OF OPHTHALMIC SURGERY. Second edition, revised by Mr. 
Laurence. With numerous illus. In one 8vo. vol. Cloth, $2 75. 

LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated by 
George F. Day, M.D. With plates, and nearly 200 illustrations. 
In two large 8vo. vols., containing 1200 pages. Cloth, $6. 

A MANUAL OF CHEMICAL PHYSIOLOGY. In one very 

handsome 8vo. vol. of 336 pages. Cloth, $2 25. 

LAWSON (GEORGE). INJURIES OF THE EYE, ORBIT, AND EYE- 
LIDS, with about 100 illustrations. From the last English edition. 
In one handsome 8vo. vol. Cloth, $3 50. 

LUDLOW (J. L.) A MANUAL OF EXAMINATIONS UPON ANA- 
TOMY, PHYSIOLOGY, SURGERY, PRACTICE OF MEDICINE, 
OBSTETRICS, MATERIA MEDICA, CHEMISTRY, PHARMACY, 
AND THERAPEUTICS. To which is added a Medical Formulary. 
Third edition. In one royal 12mo. vol. of over 800 pages. Cloth, 
$3 25 ; leather, $3 75. 



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LAYCOCK (THOMAS). LECTURES ON THE PRINCIPLES AND 
METHODS OF MEDICAL OBSERVATION AND RESEARCH. In 
one 12mo. vol. Cloth, $1. 

LYNCH (W. F.) A NARRATIVE OF THE UNITED STATES EX- 
PEDITION TO THE DEAD SEA AND RIVER JORDAN. In one 
large and handsome octavo vol., with 28 beautiful plates and two 
maps. Cloth, $3. 
Same Work, condensed edition. One vol. royal 12mo. Cloth, $1. 

LEE (HENRY) ON SYPHILIS. In one handsome 8vo. vol. Cloth, 
$2 25. {Just issued.) 

LYONS (ROBERT D.) A TREATISE ON FEVER. In one neat 8vo. 
vol. of 362 pages. Cloth, $2 25. 



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ARSHALL (JOHN). OUTLINES OF PHYSIOLOGY, HUMAN 
AND COMPARATIVE. With Additions by Francis G. Smith. 
M. D., Professor of the Institutes of Medicine in the University of 
Pennsylvania. In one 8vo. volume of 1026 pages, with 122 illustra- 
tions. Strongly bound in leather, raised bands, $7 50. Cloth, $6 50. 

ACLISE (JOSEPH). SURGICAL ANATOMY. In one large im- 
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taining 190 figures, many of them life size. Cloth, $14. 

EIGS (CHAS. D). ON THE NATURE, SIGNS, AND TREATMENT 
OF CHILDBED FEVER. In one 8vo. vol. of 365 pages. Cloth, $2. 

ILLER ( J AMES) . PRINCIPLES OF SURGERY. Fourth American, 
from the third Edinburgh edition. In one large 8vo. vol. of 700 
pages, with 240 illustrations. Cloth, $3 75. 

THE PRACTICE OF SURGERY. Fourth American, from the 

last Edinburgh edition. In one large 8vo. vol. of 700 pages, with 
364 illustrations. Cloth, S3 75. 

MONTGOMERY (W. F.) AN EXPOSITION OF THE SIGNS AND 
SYMPTOMS OF PREGNANCY. From the second English edition. 
In one handsome 8vo. vol. of nearly 600 pages. Cloth, $3 75. 

MULLER (J.) PRINCIPLES OF PHYSICS AND METEOROLOGY. 
In one large 8vo. vol. with 550 wood-cuts, and two colored plates. 
Cloth, $4 50. 

MIRABEATJ; A LIFE HISTORY. In one royal 12mo. vol. Cloth, 
75 cents. 

MACFARLAND'S TURKEY AND ITS DESTINY. In 2 vols, royal 
12mo. Cloth, $2. 

\ESH (MRS.) A HISTORY OF THE PROTESTANT REFORMA- 
TION IN FRANCE. In 2 vols, royal l2mo. Cloth, $2. 

NELIGAN (J.MOORE). AN ATLAS OF CUTANEOUS DISEASES. 
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